Provider Demographics
NPI:1356816326
Name:SLAYTONBRAUTOVICH, LEE ANN (LEE)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:SLAYTONBRAUTOVICH
Suffix:
Gender:F
Credentials:LEE
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:ANN
Other - Last Name:SLAYTONBRAUTOVICH-BRAUTOVICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-0051
Mailing Address - Country:US
Mailing Address - Phone:831-801-6661
Mailing Address - Fax:
Practice Address - Street 1:159 E ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5334
Practice Address - Country:US
Practice Address - Phone:209-526-2811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT3437208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty