Provider Demographics
NPI:1861599243
Name:BRACKEN, TERESA LYNN (RP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:RP
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:LYNN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RP
Mailing Address - Street 1:1520 17TH ST
Mailing Address - Street 2:
Mailing Address - City:GERING
Mailing Address - State:NE
Mailing Address - Zip Code:69341-2702
Mailing Address - Country:US
Mailing Address - Phone:308-883-1092
Mailing Address - Fax:
Practice Address - Street 1:205 W 27TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4307
Practice Address - Country:US
Practice Address - Phone:308-635-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12464183500000X
WI14371-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14371-040OtherPHARMACIST LICENSE
NE12464OtherPHARMACIST LICENSE