Provider Demographics
NPI:1649423237
Name:BRANTLEY, DANA (APN)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5183
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5183
Mailing Address - Country:US
Mailing Address - Phone:601-484-6700
Mailing Address - Fax:
Practice Address - Street 1:1800 12TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4158
Practice Address - Country:US
Practice Address - Phone:601-484-6700
Practice Address - Fax:601-703-3024
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127550363L00000X
MS903935363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO149328OtherMO LICENSE NUMBER
TX364281101Medicaid