Provider Demographics
NPI:1669838272
Name:FAIRCLOTH, BRANDY JEAN (NP-C)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:JEAN
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 CENTRAL AVE S
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-5645
Mailing Address - Country:US
Mailing Address - Phone:229-388-5690
Mailing Address - Fax:
Practice Address - Street 1:2735 CENTRAL AVE S
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-5645
Practice Address - Country:US
Practice Address - Phone:229-388-5690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN204256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily