Provider Demographics
NPI:1669019600
Name:CLARK, BRANDY LEE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 CHATTANOOGA AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2672
Mailing Address - Country:US
Mailing Address - Phone:706-876-2130
Mailing Address - Fax:
Practice Address - Street 1:1575 CHATTANOOGA AVE STE 1
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2672
Practice Address - Country:US
Practice Address - Phone:706-876-2130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA163349363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty