Provider Demographics
NPI:1154915163
Name:NORTH, BRANDI DEON
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:DEON
Last Name:NORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W 21ST ST STE R1
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4098
Mailing Address - Country:US
Mailing Address - Phone:575-935-0944
Mailing Address - Fax:575-359-6827
Practice Address - Street 1:1808 AVONDALE BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5010
Practice Address - Country:US
Practice Address - Phone:575-309-4805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM62924363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily