Provider Demographics
NPI:1548988645
Name:BRAXTON, TIA PATRICE
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:PATRICE
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8813 ARISTIDES DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-1735
Mailing Address - Country:US
Mailing Address - Phone:502-999-2855
Mailing Address - Fax:
Practice Address - Street 1:6540 OUTER LOOP STE 6
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40228-2000
Practice Address - Country:US
Practice Address - Phone:502-255-1925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018206363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health