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General NPI Number Information
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NPI Number | 1548988645
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Entity Type | Individual
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Provider Name | TIA PATRICE BRAXTON
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Gender | Female
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Dates
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Enumeration Date | 08/16/2022
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Last Update Date | 08/19/2022
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Provider Practice Location Address
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Address Line | 6540 OUTER LOOP STE 6
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City | LOUISVILLE
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State | KY
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Zip | 40228-2000
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Country | US
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Telephone | 502-255-1925
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Fax |
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Provider Business Mailing Address
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Address Line | 8813 ARISTIDES DR
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City | LOUISVILLE
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State | KY
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Zip | 40258-1735
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Country | US
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Telephone | 502-999-2855
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 3018206
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License Number State | KY
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