Healthcare Provider Details

I. General information

NPI: 1215677166
Provider Name (Legal Business Name): BRANDY SULLIVAN BRANHAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 DECLARATION DR
INDEPENDENCE KY
41051-8441
US

IV. Provider business mailing address

PO BOX 932958
CLEVELAND OH
44193-0028
US

V. Phone/Fax

Practice location:
  • Phone: 859-898-1608
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3017539
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3017539
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0030691
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: