Provider Demographics
NPI:1487196044
Name:KING-BRASWELL, CORETTA
Entity Type:Individual
Prefix:
First Name:CORETTA
Middle Name:
Last Name:KING-BRASWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1194
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30237-1194
Mailing Address - Country:US
Mailing Address - Phone:386-338-8222
Mailing Address - Fax:
Practice Address - Street 1:2822 WOODHOLLOW LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2829
Practice Address - Country:US
Practice Address - Phone:386-338-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA81-1453757171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator