Healthcare Provider Details

I. General information

NPI: 1033106679
Provider Name (Legal Business Name): MARY S BRAGG CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HIGHLAND AVE
LEWISTOWN PA
17044-1331
US

IV. Provider business mailing address

904 CAMPBELL STREET SUITE 203
WILLIAMSPORT PA
17701-2627
US

V. Phone/Fax

Practice location:
  • Phone: 717-247-7918
  • Fax: 717-247-7939
Mailing address:
  • Phone: 717-840-9885
  • Fax: 717-840-9313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW008344L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberMW008344L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: