Provider Demographics
NPI:1063106839
Name:PHELPS, BRANDON LEE
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
Last Name:PHELPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8091 BACK BAY CT APT 2A
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1766
Mailing Address - Country:US
Mailing Address - Phone:151-359-4062
Mailing Address - Fax:
Practice Address - Street 1:8091 BACK BAY CT APT 2A
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-1766
Practice Address - Country:US
Practice Address - Phone:513-496-6968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH170217164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse