Provider Demographics
NPI:1114542313
Name:CANADA, BRANDI
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:CANADA
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:PO BOX 251970
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225-1970
Mailing Address - Country:US
Mailing Address - Phone:501-660-6821
Mailing Address - Fax:501-660-6830
Practice Address - Street 1:6601 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1513
Practice Address - Country:US
Practice Address - Phone:501-660-6821
Practice Address - Fax:501-660-6830
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR225534163WP0807X, 163WP0808X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health