Provider Demographics
NPI:1356571970
Name:HEADLEE, BRANDON ELIZABETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BRANDON
Middle Name:ELIZABETH
Last Name:HEADLEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:BRANDON
Other - Middle Name:ELIZABETH
Other - Last Name:DOUGHERTY-HAMOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:717-531-4950
Practice Address - Fax:717-531-6770
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053927363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103145695Medicaid
PA103145695Medicaid