Healthcare Provider Details

I. General information

NPI: 1740954643
Provider Name (Legal Business Name): LEA HAYLEY BRAINERD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 POPLAR AVE STE 409
MEMPHIS TN
38117-4434
US

IV. Provider business mailing address

1 DR ML KING JR AVE APT 231
MEMPHIS TN
38103-1757
US

V. Phone/Fax

Practice location:
  • Phone: 901-582-7243
  • Fax:
Mailing address:
  • Phone: 901-612-1486
  • Fax: 901-425-9853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberUC-51980AFD-1B01-483
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00599
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4706
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00599
License Number StateMS
# 8
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4706
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: