Provider Demographics
NPI:1538121223
Name:BRAKKE, MARCIA ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:ANN
Last Name:BRAKKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:ANN
Other - Last Name:MOEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2925 CHICAGO AVENUE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:2925 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1321
Practice Address - Country:US
Practice Address - Phone:612-262-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR080981-6363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN675825800Medicaid
P56965Medicare UPIN
500002007Medicare ID - Type Unspecified