1477636009 NPI number — BERYL ANN BRIGHAM ACNP-BC

Table of content: BERYL ANN BRIGHAM ACNP-BC (NPI 1477636009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477636009 NPI number — BERYL ANN BRIGHAM ACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRIGHAM
Provider First Name:
BERYL
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNP-BC
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:
1477636009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2078
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76234-6156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-249-9009
Provider Business Mailing Address Fax Number:
940-626-8684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2014 BEN MERRITT DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76234-3850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-249-9009
Provider Business Practice Location Address Fax Number:
940-626-8684
Provider Enumeration Date:
10/24/2006

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: 363L00000X , with the licence number:  AP115429 , 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: 8613NZ . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 366546501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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