Healthcare Provider Details

I. General information

NPI: 1134025851
Provider Name (Legal Business Name): BRAEDEN NICOLE HEFLEY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2026
Last Update Date: 10/19/2026
Certification Date: 10/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W MAIN ST
DAVIS OK
73030-1749
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 580-369-3900
  • Fax: 580-369-3901
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4260
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: