Provider Demographics
NPI:1851361943
Name:BRAGG, BLANCHE LENORA (FNP)
Entity Type:Individual
Prefix:
First Name:BLANCHE
Middle Name:LENORA
Last Name:BRAGG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4165 30TH AVE S SUITE 101
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8419
Mailing Address - Country:US
Mailing Address - Phone:866-825-3227
Mailing Address - Fax:866-397-7399
Practice Address - Street 1:6865 W TROPICANA
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103
Practice Address - Country:US
Practice Address - Phone:866-825-3227
Practice Address - Fax:866-397-7399
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN000739363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500635Medicaid
NV1851361943Medicaid
NV100500634Medicaid
NV100500635Medicaid
NV1851361943Medicaid