Provider Demographics
NPI:1295179398
Name:HARRIS, BRANDI BAILEY (CRNA)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:BAILEY
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:JENNE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9554
Practice Address - Country:US
Practice Address - Phone:707-963-3611
Practice Address - Fax:707-967-5622
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN738706163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANA4169OtherMEDICAL LICENSE
CAHG495ZMedicare PIN