Provider Demographics
NPI:1255417838
Name:BOOTH, BRENDA GALVIN (NP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:GALVIN
Last Name:BOOTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:112 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-4908
Mailing Address - Country:US
Mailing Address - Phone:910-323-0334
Mailing Address - Fax:888-391-5874
Practice Address - Street 1:1248 FORT BRAGG RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-4981
Practice Address - Country:US
Practice Address - Phone:910-323-0334
Practice Address - Fax:888-391-5874
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5000596363L00000X
NC2005003026363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2005003026OtherAMERICAN NURSES CREDENTIALING CENTER