Healthcare Provider Details

I. General information

NPI: 1083072367
Provider Name (Legal Business Name): BRANDON LEBRON GRIGGS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 POPLAR RD STE 130
NEWNAN GA
30265-8307
US

IV. Provider business mailing address

PO BOX 102321
ATLANTA GA
30368-2321
US

V. Phone/Fax

Practice location:
  • Phone: 770-683-6291
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN253827
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNCO-000003
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: