Healthcare Provider Details

I. General information

NPI: 1073199204
Provider Name (Legal Business Name): KRISTIN BRANTLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 05/21/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 R. T. STANLEY, SR. PLACE
LYONS GA
30436-5623
US

IV. Provider business mailing address

110 RT STANLEY SENIOR PL
LYONS GA
30436-0407
US

V. Phone/Fax

Practice location:
  • Phone: 912-526-9355
  • Fax:
Mailing address:
  • Phone: 912-526-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN227376
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: