Provider Demographics
NPI:1164073441
Name:BRAGG, MARISSA ANN
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:BRAGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WEST ST
Mailing Address - Street 2:
Mailing Address - City:EAST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02333-1808
Mailing Address - Country:US
Mailing Address - Phone:781-204-0166
Mailing Address - Fax:
Practice Address - Street 1:1115 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:508-521-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program