Provider Demographics
NPI:1134991201
Name:BRAGG, KENYA
Entity type:Individual
Prefix:
First Name:KENYA
Middle Name:
Last Name:BRAGG
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 1:3188 BLUEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-4834
Mailing Address - Country:US
Mailing Address - Phone:901-585-4762
Mailing Address - Fax:
Practice Address - Street 1:3188 BLUEFIELD ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-4834
Practice Address - Country:US
Practice Address - Phone:901-585-4762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN159897376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide