=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518824846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYTEANA BRADDY
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2026
-----------------------------------------------------
Last Update Date | 01/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 628 W GRAND AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45506-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-591-0792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 628 W GRAND AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45506-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-591-0792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | 602736881123
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 602736881123
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------