Provider Demographics
NPI:1013299007
Name:MONROE, BRANDI NICHELLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:NICHELLE
Last Name:MONROE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:NICHELLE
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:678-207-4000
Practice Address - Fax:770-531-2435
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA006265363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003116076DMedicaid
GA003116076EMedicaid
GA003116076FMedicaid
GA680875OtherWELLCARE
GA01635237OtherAMERIGROUP
GA01635237OtherAMERIGROUP