MEDICARE: SPENCER LAMONT BRANTLE NP

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	363LF0000X	Family Nurse Practitioner	NP95009882	CA

General Provider Information

NPI Number	:	1215411954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPENCER LAMONT BRANTLE NP

Provider Business Mailing Address
First Line	:	7471 N FRESNO ST
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93720-2457
Country	:	US
Telephone Number	:	559-981-5566
Fax Number	:	559-228-9989

Provider Business Practice Location Address
First Line	:	7471 N FRESNO STREET
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93720-9372
Country	:	US
Telephone Number	:	559-981-5566
Fax Number	:

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

Provider Enumeration Date	:	09/19/2018
Last Update Date	:	09/19/2018

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