Provider Demographics
NPI:1942837034
Name:KVISTAD, BRANDON (RN)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:KVISTAD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 3RD AVE W UNIT 1217
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8692
Mailing Address - Country:US
Mailing Address - Phone:630-290-1274
Mailing Address - Fax:
Practice Address - Street 1:206 2ND ST E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1042
Practice Address - Country:US
Practice Address - Phone:630-290-1274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9476815163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency