Provider Demographics
NPI:1407173867
Name:BRANTLEY, JERRY LENDO JR (CRNA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LENDO
Last Name:BRANTLEY
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:LEN
Other - Middle Name:
Other - Last Name:BRANTLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2080 W ARLINGTON BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3770
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:
Practice Address - Street 1:2080 W ARLINGTON BLVD
Practice Address - Street 2:STE B
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3770
Practice Address - Country:US
Practice Address - Phone:252-752-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC186544163W00000X
NC84747367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1407173867OtherTRICARE
NC8053788Medicaid
NCP00835163OtherRAILROAD MEDICARE
NCP00835163OtherRAILROAD MEDICARE