Healthcare Provider Details

I. General information

NPI: 1417323213
Provider Name (Legal Business Name): MATTIE KRISTEN BRAZELL JULIAN WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2015
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PALMETTO HEALTH PKWY STE 300
COLUMBIA SC
29212-1763
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-907-7300
  • Fax: 803-907-7309
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number19368
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: