Provider Demographics
NPI:1306020128
Name:BRACKIN, ANITA KAY
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:KAY
Last Name:BRACKIN
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 1:440 ROSEMARY LN
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1738
Mailing Address - Country:US
Mailing Address - Phone:870-623-6222
Mailing Address - Fax:870-763-1202
Practice Address - Street 1:440 ROSEMARY LN
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1738
Practice Address - Country:US
Practice Address - Phone:870-623-6222
Practice Address - Fax:870-763-1202
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1645827827833747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider