Healthcare Provider Details

I. General information

NPI: 1649852450
Provider Name (Legal Business Name): LANESSA RENEE BRANT NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 08/01/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38A OLD SPARROWBUSH RD
LATHAM NY
12110-2927
US

IV. Provider business mailing address

3152 SYBILLA ST
CHESAPEAKE VA
23323-1413
US

V. Phone/Fax

Practice location:
  • Phone: 315-469-8700
  • Fax:
Mailing address:
  • Phone: 757-969-2965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024181259
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: