Healthcare Provider Details

I. General information

NPI: 1861983611
Provider Name (Legal Business Name): CHRYSTAL BRADEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2018
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

PO BOX 11049
NORFOLK VA
23517-0049
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7007
  • Fax:
Mailing address:
  • Phone: 757-668-7007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102207148
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: