Provider Demographics
NPI:1417323213
Name:BRAZELL JULIAN, MATTIE KRISTEN (WHNP)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:KRISTEN
Last Name:BRAZELL JULIAN
Suffix:
Gender:F
Credentials:WHNP
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:300 PALMETTO HEALTH PKWY STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1763
Practice Address - Country:US
Practice Address - Phone:803-907-7300
Practice Address - Fax:803-907-7309
Is Sole Proprietor?:No
Enumeration Date:2015-08-15
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19368363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3400Medicaid
SCNP3400Medicaid
SCSC6744C653OtherMEDICARE
SCSC6744F935OtherMEDICARE