Healthcare Provider Details

I. General information

NPI: 1063897585
Provider Name (Legal Business Name): BRANDY DIANE MACDONALD NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2015
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 ROPER CORNERS CIR
GREENVILLE SC
29615-4833
US

IV. Provider business mailing address

200 N HIGHWAY 25
TRAVELERS REST SC
29690-2300
US

V. Phone/Fax

Practice location:
  • Phone: 864-234-7815
  • Fax: 864-234-7846
Mailing address:
  • Phone: 864-834-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19647
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: