Provider Demographics
NPI:1760075196
Name:BRADDOCK, BRITTNEY
Entity Type:Individual
Prefix:
First Name:BRITTNEY
Middle Name:
Last Name:BRADDOCK
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 1:528 BAHIA CIRCLE RUN
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34472-2680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:528 BAHIA CIRCLE RUN
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34472-2680
Practice Address - Country:US
Practice Address - Phone:352-999-0797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X, 251C00000X
FL376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL832210975Medicaid