Provider Demographics
NPI:1457967556
Name:SMITH, BRANDON SHANE (RN)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:SHANE
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 DUMAINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-3420
Mailing Address - Country:US
Mailing Address - Phone:318-455-8435
Mailing Address - Fax:
Practice Address - Street 1:2630 DUMAINE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-3420
Practice Address - Country:US
Practice Address - Phone:318-455-8435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN121012163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LARN121012OtherRN LICENSE