1417323213 NPI number — MATTIE KRISTEN BRAZELL JULIAN WHNP

Table of content: MATTIE KRISTEN BRAZELL JULIAN WHNP (NPI 1417323213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417323213 NPI number — MATTIE KRISTEN BRAZELL JULIAN WHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAZELL JULIAN
Provider First Name:
MATTIE
Provider Middle Name:
KRISTEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
WHNP
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:
1417323213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743904
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-7320
Provider Business Mailing Address Fax Number:
803-296-7330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 PALMETTO HEALTH PKWY STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29212-1763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-907-7300
Provider Business Practice Location Address Fax Number:
803-907-7309
Provider Enumeration Date:
08/15/2015

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: 363LW0102X , with the licence number:  19368 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NP3400 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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