Basic Information
| Provider Information | |||||||||
| NPI: | 1962071563 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRACKEN | ||||||||
| FirstName: | SARALYN | ||||||||
| MiddleName: | WILSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRT, RRT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | SARALYN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRT, RRT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 415 MORGAN FALLS RD APT 1102 | ||||||||
| Address2: | |||||||||
| City: | SANDY SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303505852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782231279 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 JOHNSON FY RD NE | ||||||||
| Address2: | |||||||||
| City: | SANDY SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047855437 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2021 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 227900000X | 175992 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | 227900000X | 11179 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered |
No ID Information.