Provider Demographics
NPI:1720329154
Name:BRANTLY, JACQUELYN HUDAK (MMSC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:HUDAK
Last Name:BRANTLY
Suffix:
Gender:F
Credentials:MMSC
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:NICOLE
Other - Last Name:HUDAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMSC
Mailing Address - Street 1:3112 ALSTON DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-3301
Mailing Address - Country:US
Mailing Address - Phone:770-833-8386
Mailing Address - Fax:
Practice Address - Street 1:235 PEACHTREE ST NE
Practice Address - Street 2:NORTH TOWER, SUITE 2100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-1401
Practice Address - Country:US
Practice Address - Phone:770-994-9326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006743363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant