Healthcare Provider Details

I. General information

NPI: 1831458330
Provider Name (Legal Business Name): NICOLE D BRACKEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 STAGECOACH TRL
MIDDLETOWN NY
10940-7089
US

IV. Provider business mailing address

29 STAGECOACH TRL
MIDDLETOWN NY
10940-7089
US

V. Phone/Fax

Practice location:
  • Phone: 845-239-6638
  • Fax:
Mailing address:
  • Phone: 845-239-6638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number770845
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: