Healthcare Provider Details

I. General information

NPI: 1518824846
Provider Name (Legal Business Name): TYTEANA BRADDY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 W GRAND AVE
SPRINGFIELD OH
45506-2022
US

IV. Provider business mailing address

628 W GRAND AVE
SPRINGFIELD OH
45506-2022
US

V. Phone/Fax

Practice location:
  • Phone: 937-591-0792
  • Fax:
Mailing address:
  • Phone: 937-591-0792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number602736881123
License Number State
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number602736881123
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: