Provider Demographics
NPI:1467123448
Name:BRANTLEY, PAMELA DIANE (RN, FNP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DIANE
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 CORIAN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78219-3402
Mailing Address - Country:US
Mailing Address - Phone:847-845-6030
Mailing Address - Fax:
Practice Address - Street 1:2502 CORIAN GLEN DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78219-3402
Practice Address - Country:US
Practice Address - Phone:847-845-6030
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 Licenses
StateLicense IDTaxonomies
IL209023922363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily