1346354818 NPI number — DONNA L BRAZELL N.P.

Table of content: DONNA L BRAZELL N.P. (NPI 1346354818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346354818 NPI number — DONNA L BRAZELL N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAZELL
Provider First Name:
DONNA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
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:
1346354818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5219 CITY BANK PKWY STE 35
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-761-0333
Provider Business Mailing Address Fax Number:
806-782-0097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDALOU
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-892-2537
Provider Business Practice Location Address Fax Number:
806-892-2726
Provider Enumeration Date:
08/19/2006

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: 163W00000X , with the licence number:  551054 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP110366 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 018953203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 131550102 . This is a "FIRST CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8N7014 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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