Provider Demographics
NPI:1982912721
Name:BRACKETT, EQUILLA W
Entity Type:Individual
Prefix:
First Name:EQUILLA
Middle Name:W
Last Name:BRACKETT
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 1:379 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:JENKINSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30234-2313
Mailing Address - Country:US
Mailing Address - Phone:770-775-6949
Mailing Address - Fax:770-504-0783
Practice Address - Street 1:379 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:JENKINSBURG
Practice Address - State:GA
Practice Address - Zip Code:30234-2313
Practice Address - Country:US
Practice Address - Phone:770-775-6949
Practice Address - Fax:770-504-0783
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018-01-008-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility