MEDICARE: BRANDI R HENRY FNP

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	0000017372	TN

General Provider Information

NPI Number	:	1831430560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDI R HENRY FNP

Provider Business Mailing Address
First Line	:	6263 POPLAR AVE STE 1032
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-4743
Country	:	US
Telephone Number	:	731-400-0411
Fax Number	:	901-779-6968

Provider Business Practice Location Address
First Line	:	160 W UNIVERSITY PKWY STE C
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-1667
Country	:	US
Telephone Number	:	731-660-5116
Fax Number	:	731-660-5119

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

Provider Enumeration Date	:	03/05/2013
Last Update Date	:	07/21/2022

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