Provider Demographics
NPI:1215705777
Name:BRANTLEY, KELSEY GRANT (CPT)
Entity type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:GRANT
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S MAIN ST STE B2
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2251
Mailing Address - Country:US
Mailing Address - Phone:864-300-0113
Mailing Address - Fax:
Practice Address - Street 1:400 S MAIN ST STE B2
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2251
Practice Address - Country:US
Practice Address - Phone:864-300-0113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC247ZC0005X
SCN23108789246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician