Provider Demographics
NPI:1275926255
Name:BRANTLEY, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
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 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:349 BMH PHYSICIANS OFFICE BLDG
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5820
Practice Address - Country:US
Practice Address - Phone:865-980-5044
Practice Address - Fax:865-980-5090
Is Sole Proprietor?:No
Enumeration Date:2015-03-14
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19748363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ015603Medicaid
TN10350I0657Medicare PIN
TN103507I283Medicare PIN