Provider Demographics
NPI:1578518478
Name:BRACKIN, BONNIE G (CRNA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:G
Last Name:BRACKIN
Suffix:
Gender:F
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:PO BOX 932925
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2925
Mailing Address - Country:US
Mailing Address - Phone:800-364-9216
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:303 PARKWAY DR NE
Practice Address - Street 2:PMB 404
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1212
Practice Address - Country:US
Practice Address - Phone:404-265-4520
Practice Address - Fax:404-265-3894
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN053969367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1982637419OtherGROUP NPI
P00385232OtherRAILROAD MEDICARE
GA000561602DMedicaid
GAN358317OtherWELLCARE MEDICAID
GA1578518478OtherNPI
GA000561602DMedicaid
GAR12315Medicare UPIN
GA1982637419OtherGROUP NPI