Healthcare Provider Details

I. General information

NPI: 1730508128
Provider Name (Legal Business Name): JENNIFER BRAXTON-BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 11/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR STE 258
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

340 THOMAS MORE PKWY CHAPEL PLACE B STE 220
CRESTVIEW HILLS KY
41017-5100
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2211
  • Fax: 859-301-2511
Mailing address:
  • Phone: 859-301-2211
  • Fax: 859-301-2511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010601
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number366887
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1117832
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: