Healthcare Provider Details

I. General information

NPI: 1407527484
Provider Name (Legal Business Name): ABIGAIL LEIGH BRANTLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ABIGAIL LEIGH REESE MS RDN

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 TURTLE CREEK DR
TYLER TX
75701-1833
US

IV. Provider business mailing address

401 VZ COUNTY ROAD 2518
CANTON TX
75103-3872
US

V. Phone/Fax

Practice location:
  • Phone: 903-595-3942
  • Fax:
Mailing address:
  • Phone: 903-330-3970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: