Provider Demographics
NPI:1558670604
Name:QUEEN, BRANDI SELINA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:SELINA
Last Name:QUEEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:SELINA
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-1197
Mailing Address - Country:US
Mailing Address - Phone:704-624-3388
Mailing Address - Fax:704-624-3390
Practice Address - Street 1:520 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHVILLE
Practice Address - State:NC
Practice Address - Zip Code:28103-1197
Practice Address - Country:US
Practice Address - Phone:704-624-3388
Practice Address - Fax:704-624-3390
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005602Medicaid