Provider Demographics
NPI:1114551272
Name:FORD, BRANDY LEE
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:LEE
Last Name:FORD
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 1:6465 E COLONY RD
Mailing Address - Street 2:
Mailing Address - City:ELSIE
Mailing Address - State:MI
Mailing Address - Zip Code:48831-9758
Mailing Address - Country:US
Mailing Address - Phone:989-307-2893
Mailing Address - Fax:
Practice Address - Street 1:1521 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1640
Practice Address - Country:US
Practice Address - Phone:269-226-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704309996207RC0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine