Healthcare Provider Details

I. General information

NPI: 1972025179
Provider Name (Legal Business Name): BRANDON C HABKOUK DNP, APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 POPLAR AVE STE 800
MEMPHIS TN
38157-0800
US

IV. Provider business mailing address

5050 POPLAR AVE STE 800
MEMPHIS TN
38157-0800
US

V. Phone/Fax

Practice location:
  • Phone: 901-276-2662
  • Fax: 901-274-2033
Mailing address:
  • Phone: 901-276-2662
  • Fax: 901-274-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number191357
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number22919
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: