Healthcare Provider Details

I. General information

NPI: 1114312576
Provider Name (Legal Business Name): BRANDY KOTZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 GATES BLVD EMERGENCY ROOM
PORT ARTHUR TX
77642-3858
US

IV. Provider business mailing address

213 GAGE AVE
NEDERLAND TX
77627-2100
US

V. Phone/Fax

Practice location:
  • Phone: 409-989-5124
  • Fax:
Mailing address:
  • Phone: 409-719-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP127360
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: