Provider Demographics
NPI:1073199204
Name:BRANTLEY, KRISTIN (NP)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 RT STANLEY SENIOR PL
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:GA
Mailing Address - Zip Code:30436-0407
Mailing Address - Country:US
Mailing Address - Phone:912-526-9355
Mailing Address - Fax:
Practice Address - Street 1:110 R. T. STANLEY, SR. PLACE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:GA
Practice Address - Zip Code:30436-5623
Practice Address - Country:US
Practice Address - Phone:912-526-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN227376363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN227376OtherLICENSE