Provider Demographics
NPI:1740063221
Name:GANTT, BRIANA NICOLE I (FNP- BC)
Entity type:Individual
Prefix:
First Name:BRIANA
Middle Name:NICOLE
Last Name:GANTT
Suffix:I
Gender:F
Credentials:FNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 SIMS KIDD RD
Mailing Address - Street 2:
Mailing Address - City:COMER
Mailing Address - State:GA
Mailing Address - Zip Code:30629-4136
Mailing Address - Country:US
Mailing Address - Phone:706-340-3556
Mailing Address - Fax:
Practice Address - Street 1:1685 OLD PENDERGRASS RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-2705
Practice Address - Country:US
Practice Address - Phone:706-387-7637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN259582363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily