Provider Demographics
NPI:1003397027
Name:BRANNAGAN, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BRANNAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:BRANNAGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMBT
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-1038
Mailing Address - Country:US
Mailing Address - Phone:704-219-2655
Mailing Address - Fax:
Practice Address - Street 1:4706 MAGNOLIA RIDGE DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-9020
Practice Address - Country:US
Practice Address - Phone:704-219-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6239225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist