Provider Demographics
NPI:1114235363
Name:BRATCHER-JOHNSON, NIKITA NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:NIKITA
Middle Name:NICOLE
Last Name:BRATCHER-JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4580 GOLDEN WEST CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5054
Mailing Address - Country:US
Mailing Address - Phone:901-438-1829
Mailing Address - Fax:
Practice Address - Street 1:1755 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38108-1115
Practice Address - Country:US
Practice Address - Phone:901-278-3840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3528225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist