Healthcare Provider Details

I. General information

NPI: 1053899153
Provider Name (Legal Business Name): NADIYAH L BRANDON OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date: 10/18/2019
Reactivation Date: 05/12/2020

III. Provider practice location address

1841 ARROW POINT DR
SAINT LOUIS MO
63138
US

IV. Provider business mailing address

2847 OLDKNOW DR NW
ATLANTA GA
30318
US

V. Phone/Fax

Practice location:
  • Phone: 314-708-9822
  • Fax:
Mailing address:
  • Phone: 314-371-7717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number3000688782
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number300688782
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number3000688782
License Number StateGA
# 12
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number3000688782
License Number StateGA
# 13
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 14
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number105389953
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: