Provider Demographics
NPI:1588781520
Name:AZEVEDO, BRANDI MICHELLE
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:MICHELLE
Last Name:AZEVEDO
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:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:CAMINO
Mailing Address - State:CA
Mailing Address - Zip Code:95709-0586
Mailing Address - Country:US
Mailing Address - Phone:530-306-1896
Mailing Address - Fax:
Practice Address - Street 1:1360 GRAY AVE
Practice Address - Street 2:APARTMENT B
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-3242
Practice Address - Country:US
Practice Address - Phone:530-306-1896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5527174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5527OtherCAS