Provider Demographics
NPI:1740807304
Name:CAMPOS-ILESANMI, BRENDA (MSN,APRN,FNP-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:CAMPOS-ILESANMI
Suffix:
Gender:F
Credentials:MSN,APRN,FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 RANCHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-5716
Mailing Address - Country:US
Mailing Address - Phone:432-238-2046
Mailing Address - Fax:
Practice Address - Street 1:4214 ANDREWS HWY STE 102
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-4815
Practice Address - Country:US
Practice Address - Phone:432-221-5580
Practice Address - Fax:833-464-3487
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1001850363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1001850OtherSTATE LICENSE