Provider Demographics
NPI:1134821945
Name:TIA BRAXTON, APRN, PMHNP-BC, PLLC
Entity type:Organization
Organization Name:TIA BRAXTON, APRN, PMHNP-BC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIA
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:BRAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, PMHNP-BC
Authorized Official - Phone:502-999-2855
Mailing Address - Street 1:8813 ARISTIDES DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-1735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6540 OUTERLOOP STE 6
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40228
Practice Address - Country:US
Practice Address - Phone:502-999-2855
Practice Address - Fax:502-416-1493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-17
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100840510Medicaid