Provider Demographics
NPI:1467158063
Name:WEAVER-BRAXTON, SEQUETTA TENESHIA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:SEQUETTA
Middle Name:TENESHIA
Last Name:WEAVER-BRAXTON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6865 LAGRANGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-2837
Mailing Address - Country:US
Mailing Address - Phone:601-955-3901
Mailing Address - Fax:
Practice Address - Street 1:102 E CLAIBORNE AVE STE D
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-3518
Practice Address - Country:US
Practice Address - Phone:601-955-3901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN260981163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse