Provider Demographics
NPI:1548520935
Name:BRATHWAITE, STEPHANIE RENEE (NP)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:RENEE
Last Name:BRATHWAITE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:RENEE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 681789
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1789
Mailing Address - Country:US
Mailing Address - Phone:615-503-9000
Mailing Address - Fax:
Practice Address - Street 1:294 N HIGHWAY 16
Practice Address - Street 2:STE. B
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-8011
Practice Address - Country:US
Practice Address - Phone:704-483-8105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007050363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1548520935Medicaid
NC1548520935Medicaid