Provider Demographics
NPI:1104376698
Name:NICKELBERRY-BRADEN, SNERICA
Entity type:Individual
Prefix:
First Name:SNERICA
Middle Name:
Last Name:NICKELBERRY-BRADEN
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 1:2218 GENERAL TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-4772
Mailing Address - Country:US
Mailing Address - Phone:601-566-5441
Mailing Address - Fax:
Practice Address - Street 1:2218 GENERAL TAYLOR DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4772
Practice Address - Country:US
Practice Address - Phone:601-566-5441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health