Provider Demographics
NPI:1043649007
Name:BRANDOM, JOLENE
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:BRANDOM
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 1:446 DORIS RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504-8628
Mailing Address - Country:US
Mailing Address - Phone:970-712-7679
Mailing Address - Fax:
Practice Address - Street 1:446 DORIS RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81504-8628
Practice Address - Country:US
Practice Address - Phone:970-712-7679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-09
Last Update Date:2013-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO197219163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse