Provider Demographics
NPI:1023504222
Name:BRACKEN, ANGELA CHYRISSE KAIULANI (PA-C)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:CHYRISSE KAIULANI
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:
Practice Address - Street 1:4529 JESSUP GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-9407
Practice Address - Country:US
Practice Address - Phone:336-209-0026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-08125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant