Provider Demographics
NPI:1700420031
Name:BRAGG, RANDI D (NP)
Entity type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:D
Last Name:BRAGG
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:8003 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1946
Mailing Address - Country:US
Mailing Address - Phone:317-576-1335
Mailing Address - Fax:844-397-1311
Practice Address - Street 1:925 S NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-1874
Practice Address - Country:US
Practice Address - Phone:765-664-7492
Practice Address - Fax:764-400-4466
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2024-02-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71009509A363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300033704Medicaid