Healthcare Provider Details

I. General information

NPI: 1548988645
Provider Name (Legal Business Name): TIA PATRICE BRAXTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6540 OUTER LOOP STE 6
LOUISVILLE KY
40228-2000
US

IV. Provider business mailing address

8813 ARISTIDES DR
LOUISVILLE KY
40258-1735
US

V. Phone/Fax

Practice location:
  • Phone: 502-255-1925
  • Fax:
Mailing address:
  • Phone: 502-999-2855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3018206
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: