Healthcare Provider Details

I. General information

NPI: 1336385475
Provider Name (Legal Business Name): BRANDY GADDY JENKINS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2008
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 HIGHWAY 34 E
NEWNAN GA
30265-1342
US

IV. Provider business mailing address

3116 HIGHWAY 34 E
NEWNAN GA
30265-1342
US

V. Phone/Fax

Practice location:
  • Phone: 678-633-6051
  • Fax:
Mailing address:
  • Phone: 678-633-6051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN166060
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN166060
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: