Provider Demographics
NPI:1952963019
Name:BRAKHAGE, CORA LYNN (RDN, CDE)
Entity type:Individual
Prefix:MS
First Name:CORA
Middle Name:LYNN
Last Name:BRAKHAGE
Suffix:
Gender:F
Credentials:RDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7063 VETERANS PKWY
Mailing Address - Street 2:
Mailing Address - City:PELL CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35125-5114
Mailing Address - Country:US
Mailing Address - Phone:205-814-2419
Mailing Address - Fax:205-814-2429
Practice Address - Street 1:7063 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:PELL CITY
Practice Address - State:AL
Practice Address - Zip Code:35125-5114
Practice Address - Country:US
Practice Address - Phone:205-814-2419
Practice Address - Fax:205-814-2429
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1634133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1992809305Medicaid