Provider Demographics
NPI:1437412285
Name:BRAGG, MARIE ANJOLI (MS, MPHIL)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ANJOLI
Last Name:BRAGG
Suffix:
Gender:F
Credentials:MS, MPHIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 ORANGE ST
Mailing Address - Street 2:APT 1
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3859
Mailing Address - Country:US
Mailing Address - Phone:321-223-1674
Mailing Address - Fax:
Practice Address - Street 1:184 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1625
Practice Address - Country:US
Practice Address - Phone:203-688-9779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3902390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program