Provider Demographics
NPI:1215411954
Name:BRANTLE, SPENCER LAMONT (NP)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:LAMONT
Last Name:BRANTLE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7471 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2457
Mailing Address - Country:US
Mailing Address - Phone:559-981-5566
Mailing Address - Fax:559-228-9989
Practice Address - Street 1:7471 N FRESNO STREET
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-9372
Practice Address - Country:US
Practice Address - Phone:559-981-5566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95009882363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily