Healthcare Provider Details

I. General information

NPI: 1588495303
Provider Name (Legal Business Name): CHANTEASE BRAXTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 WHITE INGRAM PKWY STE 500
DALLAS GA
30132-0972
US

IV. Provider business mailing address

3349 MCEVER PARK CIR
ACWORTH GA
30101-6651
US

V. Phone/Fax

Practice location:
  • Phone: 678-363-7447
  • Fax: 678-363-7787
Mailing address:
  • Phone: 404-909-7462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN101246
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: