Provider Demographics
NPI:1689489544
Name:BRACKETT, BLAKLEY J (AGACNP)
Entity type:Individual
Prefix:
First Name:BLAKLEY
Middle Name:J
Last Name:BRACKETT
Suffix:
Gender:
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 41ST ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3931
Mailing Address - Country:US
Mailing Address - Phone:228-209-5031
Mailing Address - Fax:
Practice Address - Street 1:1391 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2419
Practice Address - Country:US
Practice Address - Phone:228-863-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS907156363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner