Provider Demographics
NPI:1780786376
Name:BRAKELEY, JOHANA KASHIWA (MD)
Entity type:Individual
Prefix:DR
First Name:JOHANA
Middle Name:KASHIWA
Last Name:BRAKELEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-1319
Mailing Address - Country:US
Mailing Address - Phone:802-388-2194
Mailing Address - Fax:802-388-1004
Practice Address - Street 1:5 SOUTH ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1319
Practice Address - Country:US
Practice Address - Phone:802-388-1002
Practice Address - Fax:802-388-1004
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT04200062262080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005148Medicaid
VT26V004OtherMVP INSURANCE
VT481306OtherCIGNA INSURANCE
VT0005148OtherBLUE CROSS & BLUE SHIELD
VT481306OtherCIGNA INSURANCE