Provider Demographics
NPI:1255037339
Name:BRAY, BRANDON (LPN)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BRAY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 1/2 GILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6018
Mailing Address - Country:US
Mailing Address - Phone:315-935-9381
Mailing Address - Fax:
Practice Address - Street 1:106 1/2 GILLIS AVE
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6018
Practice Address - Country:US
Practice Address - Phone:315-935-9381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338137-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse