Healthcare Provider Details

I. General information

NPI: 1326957697
Provider Name (Legal Business Name): BRADEN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY PLZ
CAPE GIRARDEAU MO
63701-4710
US

IV. Provider business mailing address

636 HEADDEN DR
RIDGELY TN
38080-1215
US

V. Phone/Fax

Practice location:
  • Phone: 573-986-6841
  • Fax: 573-651-5150
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: