1407913627 NPI number — MRS. CONSTANCE MARIE BRAKE MS OTRL

Table of content: DARONICA M JOHNSON-SANTOS (NPI 1457915209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407913627 NPI number — MRS. CONSTANCE MARIE BRAKE MS OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAKE
Provider First Name:
CONSTANCE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407913627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 PARK BOULEVARD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27127-2042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5415 W FRIENDLY AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27410-4255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-772-5499
Provider Business Practice Location Address Fax Number:
336-292-6064
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  4237 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13740 . This is a "BLUE CROSS AND BLUE SHIEL" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7301713 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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