Healthcare Provider Details

I. General information

NPI: 1336015312
Provider Name (Legal Business Name): KATLYN MAEGAN BRANTLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E BOND ST
ESPANOLA NM
87532-2729
US

IV. Provider business mailing address

439 PONDEROSA WAY
JEMEZ SPRINGS NM
87025-8036
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-9503
  • Fax:
Mailing address:
  • Phone: 505-240-0353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53897
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: