Provider Demographics
NPI:1629191879
Name:BRANTLEY, AUDREY A (NP)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:A
Last Name:BRANTLEY
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 1:3831 S LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-6198
Mailing Address - Country:US
Mailing Address - Phone:865-403-8672
Mailing Address - Fax:865-403-6700
Practice Address - Street 1:7300 CHAPMAN HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-6612
Practice Address - Country:US
Practice Address - Phone:865-403-8672
Practice Address - Fax:865-403-6700
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000087894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN509068Medicare UPIN
TN3341289Medicare ID - Type Unspecified