Provider Demographics
NPI:1851629703
Name:BRASWELL, STACIE (MD)
Entity type:Individual
Prefix:DR
First Name:STACIE
Middle Name:
Last Name:BRASWELL
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 1:951 TRANSPORT DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-8434
Mailing Address - Country:US
Mailing Address - Phone:219-477-6082
Mailing Address - Fax:219-465-9502
Practice Address - Street 1:1313 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3316
Practice Address - Country:US
Practice Address - Phone:219-398-9685
Practice Address - Fax:219-398-9695
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073089A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201194330Medicaid
IN193380016Medicare UPIN