Provider Demographics
NPI:1801145321
Name:BRANUM, FAYE ALICIA (PA)
Entity type:Individual
Prefix:DR
First Name:FAYE
Middle Name:ALICIA
Last Name:BRANUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0600
Mailing Address - Country:US
Mailing Address - Phone:618-303-6878
Mailing Address - Fax:
Practice Address - Street 1:2865 CHURN CREEK RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1117
Practice Address - Country:US
Practice Address - Phone:530-226-7419
Practice Address - Fax:530-224-9433
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012025737363A00000X
CAPA52974363A00000X
CA52974364SP0808X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL490903974Medicaid
CAPA52974OtherCALIFORNIA PA LICENSE