Provider Demographics
NPI:1790293215
Name:BRACK, RENEE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:BRACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19258 COTON HOLDINGS CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3867
Mailing Address - Country:US
Mailing Address - Phone:540-239-1429
Mailing Address - Fax:
Practice Address - Street 1:1101 WILSON BLVD STE 900
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22209-2248
Practice Address - Country:US
Practice Address - Phone:551-224-4546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261868163W00000X
NC5010222363LF0000X
VA0024191377363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse