Provider Demographics
NPI:1649944356
Name:BRAXTON, CASSANDRA DENISE
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:DENISE
Last Name:BRAXTON
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 1:1413 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:LA
Mailing Address - Zip Code:70444-3038
Mailing Address - Country:US
Mailing Address - Phone:985-474-6793
Mailing Address - Fax:
Practice Address - Street 1:705 FISHER LN
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:LA
Practice Address - Zip Code:70444
Practice Address - Country:US
Practice Address - Phone:985-474-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008683583251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA008430288Medicaid