Healthcare Provider Details

I. General information

NPI: 1376052860
Provider Name (Legal Business Name): MARY HAZEL BRANTLEY MSN, RN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 COLLEGE DR RM 400
VERNON TX
76384-3166
US

IV. Provider business mailing address

4301 COLLEGE DR RM 400
VERNON TX
76384-3166
US

V. Phone/Fax

Practice location:
  • Phone: 940-553-2802
  • Fax: 940-553-2893
Mailing address:
  • Phone: 940-553-2802
  • Fax: 940-553-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP135219
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: