Provider Demographics
NPI:1740954643
Name:BRAINERD, LEA HAYLEY (PA-C)
Entity type:Individual
Prefix:MS
First Name:LEA
Middle Name:HAYLEY
Last Name:BRAINERD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DR ML KING JR AVE APT 231
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-1757
Mailing Address - Country:US
Mailing Address - Phone:901-612-1486
Mailing Address - Fax:901-425-9853
Practice Address - Street 1:4646 POPLAR AVE STE 409
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4434
Practice Address - Country:US
Practice Address - Phone:901-582-7243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UC-51980AFD-1B01-483171400000X
261QM1300X, 363A00000X, 363AM0700X
MSPA00599363A00000X, 363AM0700X
TN4706363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1188566OtherNCCPA CERTIFICATION
TN4706OtherSTATE LICENSE
MSPA00599OtherSTATE LICENSE