Provider Demographics
NPI:1891971578
Name:BRAXLEY, NICOLE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:BRAXLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 920
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 POWELL ST
Practice Address - Street 2:SUITE 920
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1826
Practice Address - Country:US
Practice Address - Phone:510-350-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-13
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002776207P00000X
CAA116841207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8907069Medicare PIN