Provider Demographics
NPI:1639795164
Name:HALEY, BRENDA DENISE I
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:DENISE
Last Name:HALEY
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:DENISE
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3272 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-3114
Mailing Address - Country:US
Mailing Address - Phone:901-864-3742
Mailing Address - Fax:
Practice Address - Street 1:3272 PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-3114
Practice Address - Country:US
Practice Address - Phone:901-864-3742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-20
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN084292842172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN084292842Medicaid
TN08492842Medicaid