Provider Demographics
NPI:1285088252
Name:BALLANTYNE, BRANDI LEIGH (CNP)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:LEIGH
Last Name:BALLANTYNE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 837
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45012-0837
Mailing Address - Country:US
Mailing Address - Phone:513-454-1111
Mailing Address - Fax:
Practice Address - Street 1:3045 BUSENBARK RD STE B
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:OH
Practice Address - Zip Code:45067-7611
Practice Address - Country:US
Practice Address - Phone:513-454-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019636363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0194819Medicaid