Provider Demographics
NPI:1649423237
Name:BRANTLEY, DANA (APN)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 LEIGH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3014
Mailing Address - Country:US
Mailing Address - Phone:662-328-1012
Mailing Address - Fax:662-328-1507
Practice Address - Street 1:5002 HIGHWAY 39 N BLDG C
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1078
Practice Address - Country:US
Practice Address - Phone:601-385-9111
Practice Address - Fax:662-328-1507
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127550363L00000X
MS903935363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO149328OtherMO LICENSE NUMBER
TX364281101Medicaid