Provider Demographics
NPI:1588495303
Name:BRAXTON, CHANTEASE
Entity type:Individual
Prefix:
First Name:CHANTEASE
Middle Name:
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 1:3349 MCEVER PARK CIR
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6651
Mailing Address - Country:US
Mailing Address - Phone:404-909-7462
Mailing Address - Fax:
Practice Address - Street 1:311 WHITE INGRAM PKWY STE 500
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-0972
Practice Address - Country:US
Practice Address - Phone:678-363-7447
Practice Address - Fax:678-363-7787
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN101246164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse