Healthcare Provider Details

I. General information

NPI: 1376505099
Provider Name (Legal Business Name): MARY COLLEEN BRACKEN A.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4979 HARLEM RD
AMHERST NY
14226-2547
US

IV. Provider business mailing address

4979 HARLEM RD
AMHERST NY
14226-2547
US

V. Phone/Fax

Practice location:
  • Phone: 716-923-4380
  • Fax: 716-923-4384
Mailing address:
  • Phone: 716-923-4380
  • Fax: 716-923-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303660
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: