Provider Demographics
NPI:1396490579
Name:BRAXTON, MONICA AMENA (LPN)
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:AMENA
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14620 WESTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2298
Mailing Address - Country:US
Mailing Address - Phone:313-949-9914
Mailing Address - Fax:
Practice Address - Street 1:3737 LAWTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2500
Practice Address - Country:US
Practice Address - Phone:313-361-6136
Practice Address - Fax:313-361-6210
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703109635164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703109635Medicaid