Provider Demographics
NPI:1881824332
Name:BRACKERT, SANDRA ROSE (NP)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:ROSE
Last Name:BRACKERT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 SANTA MONICA BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2067
Mailing Address - Country:US
Mailing Address - Phone:310-829-5471
Mailing Address - Fax:310-829-6192
Practice Address - Street 1:2336 SANTA MONICA BLVD STE 301
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2067
Practice Address - Country:US
Practice Address - Phone:310-829-5471
Practice Address - Fax:310-829-6192
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 17550363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner