Provider Demographics
NPI:1851827430
Name:BRANTLEY, ERIN NICHOLE (PA)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:NICHOLE
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:ERIN
Other - Middle Name:NICHOLE
Other - Last Name:MINGLEDORFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:64 OMEGA DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4221
Mailing Address - Country:US
Mailing Address - Phone:678-206-7155
Mailing Address - Fax:
Practice Address - Street 1:758 OLD NORCROSS RD STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3386
Practice Address - Country:US
Practice Address - Phone:770-962-4300
Practice Address - Fax:770-339-7544
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant