Healthcare Provider Details

I. General information

NPI: 1154915163
Provider Name (Legal Business Name): BRANDI DEON NORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 02/22/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 AVONDALE BLVD
CLOVIS NM
88101-5010
US

IV. Provider business mailing address

2000 W 21ST ST STE R1
CLOVIS NM
88101-4098
US

V. Phone/Fax

Practice location:
  • Phone: 575-309-4805
  • Fax:
Mailing address:
  • Phone: 575-935-0944
  • Fax: 575-359-6827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number62924
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: