MEDICARE: BRANDI MERCEDES PRYOR HCO PROVIDER

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	172V00000X	Community Health Worker	2978-01-001	VA
2	172V00000X	Community Health Worker	HCO-222657	VA

General Provider Information

NPI Number	:	1306486683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDI MERCEDES PRYOR HCO PROVIDER

Provider Business Mailing Address
First Line	:	2412 CREEKMORE CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8843
Country	:	US
Telephone Number	:	757-319-0912
Fax Number	:

Provider Business Practice Location Address
First Line	:	3574 HOLLAND RD STE 204
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-4063
Country	:	US
Telephone Number	:	757-220-2396
Fax Number	:	757-220-2396

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

Provider Enumeration Date	:	01/14/2020
Last Update Date	:	08/31/2021

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