Provider Demographics
NPI:1326503897
Name:PUGH, BRANDI LAWANE
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:LAWANE
Last Name:PUGH
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 1:122 SILVER LAKE CT
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-7032
Mailing Address - Country:US
Mailing Address - Phone:478-731-9387
Mailing Address - Fax:
Practice Address - Street 1:5451 BOWMAN RD STE 240
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5787
Practice Address - Country:US
Practice Address - Phone:478-259-0889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 2255A2300X
GACHRI011113111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer