Healthcare Provider Details

I. General information

NPI: 1861982977
Provider Name (Legal Business Name): BRANDEE DANIELLE DITTBRENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 HULL RD
GAINESVILLE FL
32607-3260
US

IV. Provider business mailing address

PO BOX 301
POPLAR WI
54864-0301
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7001
  • Fax:
Mailing address:
  • Phone: 218-409-2929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL5660
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: