1053530030 NPI number — MS. MARY DEBORAH BRALLIER ARNP

Table of content: MS. MARY DEBORAH BRALLIER ARNP (NPI 1053530030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053530030 NPI number — MS. MARY DEBORAH BRALLIER ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRALLIER
Provider First Name:
MARY
Provider Middle Name:
DEBORAH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1053530030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
263 SW ACE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32025-1652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-623-2050
Provider Business Mailing Address Fax Number:
386-719-2436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7019 NW 11TH PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32605-3145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-376-1611
Provider Business Practice Location Address Fax Number:
352-379-7473
Provider Enumeration Date:
04/25/2007

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: 363LF0000X , with the licence number:  ARNP 0935112 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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