Healthcare Provider Details

I. General information

NPI: 1730024779
Provider Name (Legal Business Name): MANDY LYNE BRACY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 TANDBERG TRL STE G
WINDHAM ME
04062-5206
US

IV. Provider business mailing address

54 C ST
SOUTH PORTLAND ME
04106-2807
US

V. Phone/Fax

Practice location:
  • Phone: 207-893-8359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP261209
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: