MEDICARE: BRANDI GOURLAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	4703116169	MI

General Provider Information

NPI Number	:	1043726698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDI GOURLAY

Provider Business Mailing Address
First Line	:	3921 ARLINGTON AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3764
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3921 ARLINGTON AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3764
Country	:	US
Telephone Number	:	810-984-8962
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2017
Last Update Date	:	12/19/2017

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