Provider Demographics
NPI:1912789322
Name:RETASKIE, BRANDI RAEANN (LPN)
Entity Type:Individual
Prefix:MISS
First Name:BRANDI
Middle Name:RAEANN
Last Name:RETASKIE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2083 HURON ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-1429
Mailing Address - Country:US
Mailing Address - Phone:906-251-1667
Mailing Address - Fax:
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-226-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703096033164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse