Healthcare Provider Details

I. General information

NPI: 1801813787
Provider Name (Legal Business Name): GREGORY H BRANDENBURG ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WEST MAIN STREET
VINE GROVE KY
40175-1302
US

IV. Provider business mailing address

101 WEST MAIN STREET
VINE GROVE KY
40175-1302
US

V. Phone/Fax

Practice location:
  • Phone: 270-877-6672
  • Fax: 270-877-6679
Mailing address:
  • Phone: 270-877-6672
  • Fax: 270-877-6679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3370P
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: