Healthcare Provider Details

I. General information

NPI: 1225342090
Provider Name (Legal Business Name): AUDRA N. BRANHAM AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUDRA N. BROOKS AU.D.

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 BOARDMAN CANFIELD RD SOUTH BRIDGE WEST, C1
BOARDMAN OH
44512-4300
US

IV. Provider business mailing address

755 BOARDMAN CANFIELD RD SOUTH BRIDGE WEST, C1
BOARDMAN OH
44512-4300
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-8155
  • Fax:
Mailing address:
  • Phone: 330-726-8155
  • Fax: 330-726-8155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA.01753
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License NumberA.01753
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License NumberA.01753
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberA.01753
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: