Healthcare Provider Details

I. General information

NPI: 1972087146
Provider Name (Legal Business Name): FELISH DESHA BRAXTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E OLIN AVE
MADISON WI
53713-1434
US

IV. Provider business mailing address

210 E OLIN AVE
MADISON WI
53713-1434
US

V. Phone/Fax

Practice location:
  • Phone: 608-807-1428
  • Fax: 608-807-1429
Mailing address:
  • Phone: 608-807-1428
  • Fax: 608-807-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number229046-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number229046
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: