Provider Demographics
NPI:1811443179
Name:FULBRIGHT, BRANDIE
Entity type:Individual
Prefix:
First Name:BRANDIE
Middle Name:
Last Name:FULBRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5322 22ND STREET
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407
Mailing Address - Country:US
Mailing Address - Phone:210-268-7759
Mailing Address - Fax:
Practice Address - Street 1:5322 22ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2117
Practice Address - Country:US
Practice Address - Phone:210-268-7759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007350315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX007350Medicaid