Provider Demographics
NPI:1417841404
Name:BRAMBLE, DERRICK SHAWN
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:SHAWN
Last Name:BRAMBLE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 W ENON RD
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-8548
Mailing Address - Country:US
Mailing Address - Phone:937-272-4925
Mailing Address - Fax:
Practice Address - Street 1:2960 W ENON RD
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-8548
Practice Address - Country:US
Practice Address - Phone:937-272-4925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005064175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist