Healthcare Provider Details

I. General information

NPI: 1922919984
Provider Name (Legal Business Name): LANELLE BRANDON WITCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 QUARTERMASTER DR
SANFORD NC
27330-7424
US

IV. Provider business mailing address

116 QUARTERMASTER DR
SANFORD NC
27330-7424
US

V. Phone/Fax

Practice location:
  • Phone: 856-246-6266
  • Fax:
Mailing address:
  • Phone: 856-246-6266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number20251415701
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: