Provider Demographics
NPI:1023570793
Name:BRANTLEY, MODENA
Entity Type:Individual
Prefix:
First Name:MODENA
Middle Name:
Last Name:BRANTLEY
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 1:2470 WILLOW DR SW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-3348
Mailing Address - Country:US
Mailing Address - Phone:330-984-8793
Mailing Address - Fax:
Practice Address - Street 1:2470 WILLOW DR SW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-3348
Practice Address - Country:US
Practice Address - Phone:330-984-8793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide