Healthcare Provider Details

I. General information

NPI: 1861366932
Provider Name (Legal Business Name): KELLY SUE BRACKEN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E EVERGREEN BLVD STE 217
VANCOUVER WA
98660-3264
US

IV. Provider business mailing address

400 E EVERGREEN BLVD STE 217
VANCOUVER WA
98660-3264
US

V. Phone/Fax

Practice location:
  • Phone: 509-596-1138
  • Fax: 971-308-7811
Mailing address:
  • Phone: 509-596-1138
  • Fax: 971-308-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP70050596
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: