Provider Demographics
NPI:1720374515
Name:BRAXTON, IVONNE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 KINGSBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76262-4908
Mailing Address - Country:US
Mailing Address - Phone:956-650-0186
Mailing Address - Fax:
Practice Address - Street 1:6115 CAMP BOWIE BLVD STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5500
Practice Address - Country:US
Practice Address - Phone:817-416-5698
Practice Address - Fax:817-416-5699
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX677692363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily