Provider Demographics
NPI:1285477018
Name:TELLER, BRANDON BLAKE (FNP)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:BLAKE
Last Name:TELLER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 US-61N
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-6094
Mailing Address - Country:US
Mailing Address - Phone:601-415-6161
Mailing Address - Fax:
Practice Address - Street 1:2100 US-61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-4500
Practice Address - Country:US
Practice Address - Phone:601-415-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS918907163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Multi-Specialty