Provider Demographics
NPI:1225342090
Name:BRANHAM, AUDRA N (AUD)
Entity Type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:N
Last Name:BRANHAM
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:DR
Other - First Name:AUDRA
Other - Middle Name:N
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:755 BOARDMAN CANFIELD RD
Mailing Address - Street 2:SOUTH BRIDGE WEST, C1
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4300
Mailing Address - Country:US
Mailing Address - Phone:330-726-8155
Mailing Address - Fax:330-726-8155
Practice Address - Street 1:755 BOARDMAN CANFIELD RD
Practice Address - Street 2:SOUTH BRIDGE WEST, C1
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4300
Practice Address - Country:US
Practice Address - Phone:330-726-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA.01753231H00000X, 231HA2400X, 231HA2500X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0516301Medicaid
OH0516301Medicaid