Provider Demographics
NPI:1184289092
Name:ROBERTS, BRANDI JEAN
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:JEAN
Last Name:ROBERTS
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 1:4249 DESPERADO CT
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-8601
Mailing Address - Country:US
Mailing Address - Phone:775-219-9365
Mailing Address - Fax:
Practice Address - Street 1:4249 DESPERADO CT
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-8601
Practice Address - Country:US
Practice Address - Phone:775-219-9365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVN.A.3747P1801X
NV3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV109316Medicaid