Provider Demographics
NPI:1477366805
Name:BRAITHWAITE, TRACY R
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:R
Last Name:BRAITHWAITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 524
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0524
Mailing Address - Country:US
Mailing Address - Phone:435-851-3459
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 524
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-0524
Practice Address - Country:US
Practice Address - Phone:435-851-3459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program