Provider Demographics
NPI:1508483371
Name:BENNETT, BRANDI NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:NICOLE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19588 ENOCH RD
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36421-6108
Mailing Address - Country:US
Mailing Address - Phone:334-343-0014
Mailing Address - Fax:
Practice Address - Street 1:215 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-5354
Practice Address - Country:US
Practice Address - Phone:334-222-4327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-28
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-140569363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty