Healthcare Provider Details

I. General information

NPI: 1205907565
Provider Name (Legal Business Name): KENYATTA D. BRANTLEY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3339 HIGHWAY 34 E
SHARPSBURG GA
30277-3564
US

IV. Provider business mailing address

15933 CLAYTON RD STE 210
BALLWIN MO
63011-2172
US

V. Phone/Fax

Practice location:
  • Phone: 770-304-2025
  • Fax:
Mailing address:
  • Phone: 636-200-4393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003563
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT003563
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: