Healthcare Provider Details

I. General information

NPI: 1023715968
Provider Name (Legal Business Name): BRANDALON MARIE FLY APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 NEW BYHALIA RD
COLLIERVILLE TN
38017-3716
US

IV. Provider business mailing address

150 COTTON GIN RD
ROSSVILLE TN
38066-5028
US

V. Phone/Fax

Practice location:
  • Phone: 901-492-4920
  • Fax:
Mailing address:
  • Phone: 731-618-9634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905911
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33359
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: