Provider Demographics
NPI:1467645051
Name:BRACE, JACALYN A (CRNP)
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:A
Last Name:BRACE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 11TH ST
Mailing Address - Street 2:SUITE 6350
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-955-6540
Mailing Address - Fax:215-923-0835
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:SUITE 6350
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-6540
Practice Address - Fax:215-923-0835
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA119659PAGMedicare PIN