1760468383 NPI number — BRANDI S JERNANDER NP-C

Table of content: BRANDI S JERNANDER NP-C (NPI 1760468383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760468383 NPI number — BRANDI S JERNANDER NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JERNANDER
Provider First Name:
BRANDI
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAMBO
Provider Other First Name:
BRANDI
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760468383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 PERRY HWY
Provider Second Line Business Mailing Address:
BLDG A
Provider Business Mailing Address City Name:
HAWKINSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31036-6748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-783-4307
Provider Business Mailing Address Fax Number:
478-783-4309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 PERRY HWY
Provider Second Line Business Practice Location Address:
BLDG A
Provider Business Practice Location Address City Name:
HAWKINSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31036-6748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-783-4307
Provider Business Practice Location Address Fax Number:
478-783-4309
Provider Enumeration Date:
12/15/2005

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:  RN149163 NP , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 432259684A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 432259684B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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