Provider Demographics
NPI:1033106679
Name:BRAGG, MARY S (CNM)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:BRAGG
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 CAMPBELL STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-2627
Mailing Address - Country:US
Mailing Address - Phone:717-840-9885
Mailing Address - Fax:717-840-9313
Practice Address - Street 1:130 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-1331
Practice Address - Country:US
Practice Address - Phone:717-247-7918
Practice Address - Fax:717-247-7939
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW008344L176B00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA035250Medicare ID - Type Unspecified