Provider Demographics
NPI:1174278808
Name:BRASELTON PEDIATRICS, LLC
Entity Type:Organization
Organization Name:BRASELTON PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:678-455-8212
Mailing Address - Street 1:1897 HIGHWAY 211 NW STE 100
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-3513
Mailing Address - Country:US
Mailing Address - Phone:678-820-7979
Mailing Address - Fax:678-820-7980
Practice Address - Street 1:1897 HIGHWAY 211 NW STE 100
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-3513
Practice Address - Country:US
Practice Address - Phone:678-820-7979
Practice Address - Fax:678-820-7980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003113444EMedicaid