Provider Demographics
NPI:1306370432
Name:TOLLIVER, BRANDY (APN)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:APN
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 13129
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-1129
Mailing Address - Country:US
Mailing Address - Phone:503-814-1472
Mailing Address - Fax:
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-814-1172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-15
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015879363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology