Provider Demographics
NPI:1407527484
Name:BRANTLEY, ABIGAIL LEIGH
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:LEIGH
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:LEIGH
Other - Last Name:REESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS RDN
Mailing Address - Street 1:401 VZ COUNTY ROAD 2518
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103-3872
Mailing Address - Country:US
Mailing Address - Phone:903-330-3970
Mailing Address - Fax:
Practice Address - Street 1:706 TURTLE CREEK DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1833
Practice Address - Country:US
Practice Address - Phone:903-595-3942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric