Provider Demographics
NPI:1346856242
Name:BRANDLY, MARISSA JEAN
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:JEAN
Last Name:BRANDLY
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 1:768 W CASTLEBURY CIR
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-1348
Mailing Address - Country:US
Mailing Address - Phone:734-219-8361
Mailing Address - Fax:
Practice Address - Street 1:768 W CASTLEBURY CIR
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1348
Practice Address - Country:US
Practice Address - Phone:734-219-8361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12366Medicaid