Healthcare Provider Details

I. General information

NPI: 1861341893
Provider Name (Legal Business Name): MARY ALICE BRANDON RN, CLNC,CIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20620 RIVER RD
SUTHERLAND VA
23885-9539
US

IV. Provider business mailing address

20620 RIVER RD
SUTHERLAND VA
23885-9539
US

V. Phone/Fax

Practice location:
  • Phone: 804-691-3193
  • Fax: 804-691-3193
Mailing address:
  • Phone: 804-691-3193
  • Fax: 804-691-3193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License Number123-4054-731184
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001180795
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: