Provider Demographics
NPI:1790384022
Name:GREGORY, BRANDI LEE
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:LEE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-1811
Mailing Address - Country:US
Mailing Address - Phone:419-775-6399
Mailing Address - Fax:
Practice Address - Street 1:53 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1811
Practice Address - Country:US
Practice Address - Phone:419-775-6393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH347C00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No347C00000XTransportation ServicesPrivate Vehicle