Healthcare Provider Details

I. General information

NPI: 1215411954
Provider Name (Legal Business Name): SPENCER LAMONT BRANTLE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7471 N FRESNO STREET
FRESNO CA
93720-9372
US

IV. Provider business mailing address

7471 N FRESNO ST
FRESNO CA
93720-2457
US

V. Phone/Fax

Practice location:
  • Phone: 559-981-5566
  • Fax:
Mailing address:
  • Phone: 559-981-5566
  • Fax: 559-228-9989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95009882
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: