Provider Demographics
NPI:1619451028
Name:JEFFERSON, BRANDY NICOLE
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:NICOLE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 SALINE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GLENN HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:75154-7968
Mailing Address - Country:US
Mailing Address - Phone:469-530-7167
Mailing Address - Fax:
Practice Address - Street 1:1255 W 15TH ST STE 1025
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7253
Practice Address - Country:US
Practice Address - Phone:972-673-0404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201946164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse