Provider Demographics
NPI:1295208783
Name:BRAKKE, ALICIA KAY
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:KAY
Last Name:BRAKKE
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 1:12157 N TONGASS HWY
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-9331
Mailing Address - Country:US
Mailing Address - Phone:605-280-5434
Mailing Address - Fax:
Practice Address - Street 1:344 FRONT ST STE A
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-6431
Practice Address - Country:US
Practice Address - Phone:605-280-5434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246QM0706X
AK225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist