Healthcare Provider Details

I. General information

NPI: 1760295075
Provider Name (Legal Business Name): AMY GRACE BRANDEBURG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY GRACE FISTER

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 01/30/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 WALNUT GROVE RD
MEMPHIS TN
38120-2113
US

IV. Provider business mailing address

265 BROOKVIEW CENTRE WAY STE 400
KNOXVILLE TN
37919-4052
US

V. Phone/Fax

Practice location:
  • Phone: 901-226-5000
  • Fax:
Mailing address:
  • Phone: 800-342-2898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: