Provider Demographics
NPI:1720220221
Name:BRADEN, DEBRA L (RN)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:BRADEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-9339
Mailing Address - Country:US
Mailing Address - Phone:269-445-2451
Mailing Address - Fax:269-445-3216
Practice Address - Street 1:960 E STATE ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-9339
Practice Address - Country:US
Practice Address - Phone:269-445-2451
Practice Address - Fax:269-445-3216
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704189244163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI774349006Medicaid