Provider Demographics
NPI:1730255357
Name:BRACKLEIN, KRISTEN J (DO)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:J
Last Name:BRACKLEIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KRISTEN
Other - Middle Name:J
Other - Last Name:PAK / KOZMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:7700 CODY LN
Mailing Address - Street 2:APT3306
Mailing Address - City:SACHSE
Mailing Address - State:TX
Mailing Address - Zip Code:75048-6629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 BLOOD RD
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-9575
Practice Address - Country:US
Practice Address - Phone:432-212-2944
Practice Address - Fax:734-661-0406
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012874207Q00000X
TXK5173207Q00000X
ORDO205724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX29935601Medicaid
TX29935601Medicaid