Provider Demographics
NPI:1336603737
Name:BRACK, SHARON LYNN (HHC, CPT, AADP)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:LYNN
Last Name:BRACK
Suffix:
Gender:F
Credentials:HHC, CPT, AADP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2581 W HIGHLAND CT
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7830
Mailing Address - Country:US
Mailing Address - Phone:480-220-9882
Mailing Address - Fax:
Practice Address - Street 1:2581 W HIGHLAND CT
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-7830
Practice Address - Country:US
Practice Address - Phone:480-220-9882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty