Provider Demographics
NPI:1407693807
Name:BURRELL, BRENTON
Entity type:Individual
Prefix:MR
First Name:BRENTON
Middle Name:
Last Name:BURRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CHANDLER DR
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-6140
Mailing Address - Country:US
Mailing Address - Phone:706-201-7726
Mailing Address - Fax:
Practice Address - Street 1:5401 LAKE OCONEE PKWY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-4232
Practice Address - Country:US
Practice Address - Phone:706-201-7726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN294310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily