Provider Demographics
NPI:1790099323
Name:DANIEL, BRENDA JEAN (RN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:DANIEL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8760 OAKCHASE CV
Mailing Address - Street 2:
Mailing Address - City:WALLS
Mailing Address - State:MS
Mailing Address - Zip Code:38680-9400
Mailing Address - Country:US
Mailing Address - Phone:662-404-6454
Mailing Address - Fax:662-342-7676
Practice Address - Street 1:1200 STATELINE RD W STE 7
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1430
Practice Address - Country:US
Practice Address - Phone:662-342-7676
Practice Address - Fax:662-342-7675
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000066174174H00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No174H00000XOther Service ProvidersHealth Educator