Provider Demographics
NPI:1801890132
Name:BRANTLEY, VIRGINIA LYNN (ARNP)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LYNN
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 STATE ROAD 415
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6012
Mailing Address - Country:US
Mailing Address - Phone:407-322-8645
Mailing Address - Fax:
Practice Address - Street 1:2400 S.R. 415
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6012
Practice Address - Country:US
Practice Address - Phone:407-322-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1183862363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305641400Medicaid
FL192242OtherHEALTHEASE
FL305641400Medicaid
FLQ07411Medicare UPIN