Provider Demographics
NPI:1992083265
Name:EASTHAM, BRENDA KAY (APRN)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:EASTHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:K
Other - Last Name:HERTLEIN EASTHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANP
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9560
Mailing Address - Fax:239-343-9624
Practice Address - Street 1:8925 COLONIAL CENTER DR STE 1000
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905
Practice Address - Country:US
Practice Address - Phone:239-343-9560
Practice Address - Fax:239-343-9624
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9441580363LA2200X
FLARNP9441580363LA2200X
DELB-0000252363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019276800Medicaid