Provider Demographics
NPI:1013327865
Name:BRANTLEY, ANGELA SELENA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:ANGELA
Middle Name:SELENA
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26705 W CARNEGIE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-6164
Mailing Address - Country:US
Mailing Address - Phone:313-648-2259
Mailing Address - Fax:
Practice Address - Street 1:26705 W CARNEGIE PARK DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-6164
Practice Address - Country:US
Practice Address - Phone:313-648-2259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703111095164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse