Healthcare Provider Details

I. General information

NPI: 1114542313
Provider Name (Legal Business Name): BRANDI CANADA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 W 12TH ST
LITTLE ROCK AR
72204-1513
US

IV. Provider business mailing address

PO BOX 251970
LITTLE ROCK AR
72225-1970
US

V. Phone/Fax

Practice location:
  • Phone: 501-660-6821
  • Fax: 501-660-6830
Mailing address:
  • Phone: 501-660-6821
  • Fax: 501-660-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number225534
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number225534
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number225534
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: