Provider Demographics
NPI:1972854255
Name:BRAXTON, KATHY ANDREA (RN)
Entity Type:Individual
Prefix:MISS
First Name:KATHY
Middle Name:ANDREA
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20212 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1930
Mailing Address - Country:US
Mailing Address - Phone:313-424-3944
Mailing Address - Fax:
Practice Address - Street 1:20212 RYAN RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1930
Practice Address - Country:US
Practice Address - Phone:313-424-3944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704235556163W00000X, 372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No372500000XNursing Service Related ProvidersChore Provider