Provider Demographics
NPI:1437114741
Name:BRACKETT, FRED (CRNA)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:BRACKETT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8255 BRACKETT LN
Mailing Address - Street 2:
Mailing Address - City:SEMMES
Mailing Address - State:AL
Mailing Address - Zip Code:36575-4550
Mailing Address - Country:US
Mailing Address - Phone:251-649-4414
Mailing Address - Fax:251-649-8283
Practice Address - Street 1:2451 FILLINGIM ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-471-7177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-031202367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALR38415Medicare UPIN