1710409883 NPI number — ERICA ELLIOTT BRUMLEY FNP

Table of content: ERICA ELLIOTT BRUMLEY FNP (NPI 1710409883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710409883 NPI number — ERICA ELLIOTT BRUMLEY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUMLEY
Provider First Name:
ERICA
Provider Middle Name:
ELLIOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1710409883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 849
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK GROVE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71263-0849
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:
608 S HIGHWAY 65 82 STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE VILLAGE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71653-1744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-265-9810
Provider Business Practice Location Address Fax Number:
870-265-9813
Provider Enumeration Date:
07/11/2017

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:  AP09412 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: A005285 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A005285 . This is a "CERTIFIED NURSE PRACTIONER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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