Provider Demographics
NPI:1376505099
Name:BRACKEN, MARY COLLEEN (ANP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:COLLEEN
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4979 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-2547
Mailing Address - Country:US
Mailing Address - Phone:716-923-4380
Mailing Address - Fax:716-923-4384
Practice Address - Street 1:4979 HARLEM RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-2547
Practice Address - Country:US
Practice Address - Phone:716-923-4380
Practice Address - Fax:716-923-4384
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303660363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM166192295OtherEMPIRE
NY166192295OtherGHI
NM9512547OtherINDEPENDENT HEALTH
NY000560845003OtherBLUE CROSS
NY060065956OtherRAILROAD MEDICARE
NY00026705402OtherUNIVERA
NY000560845003OtherCOMMUNITY BLUE
NYBB1937Medicare PIN
NM166192295OtherEMPIRE