Provider Demographics
NPI:1215559687
Name:BRACKENRICH, ROBERT NOLAN (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:NOLAN
Last Name:BRACKENRICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SAINT JOSEPHS CANDLER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9585
Mailing Address - Country:US
Mailing Address - Phone:912-748-1999
Mailing Address - Fax:
Practice Address - Street 1:101 SAINT JOSEPHS CANDLER DR STE 200
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9585
Practice Address - Country:US
Practice Address - Phone:912-748-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA97632207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine