Provider Demographics
NPI:1942891569
Name:BRANTLEY, NICHOLAS SR
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BRANTLEY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 MARS HILL LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-4327
Mailing Address - Country:US
Mailing Address - Phone:727-804-8193
Mailing Address - Fax:
Practice Address - Street 1:5524 MARS HILL LN
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-4327
Practice Address - Country:US
Practice Address - Phone:727-804-8193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11010854363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily