Provider Demographics
NPI:1568915171
Name:BRACHA, MARY M (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:BRACHA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:MCAULIFFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:10330 N MERIDIAN ST # 300
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 RACE STREET
Practice Address - Street 2:APT1001
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-0000
Practice Address - Country:US
Practice Address - Phone:610-619-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-31
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP019005363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103562366Medicaid