Healthcare Provider Details

I. General information

NPI: 1588210330
Provider Name (Legal Business Name): BRANDI CANTRELL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRANDI M HORNER

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7650 E PARHAM RD STE 110
RICHMOND VA
23294-4376
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 804-916-7062
  • Fax: 804-918-2172
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0024177836
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024177836
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: