Basic Information
| Provider Information | |||||||||
| NPI: | 1114385721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDLE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284977576 | ||||||||
| FaxNumber: | 2284978869 | ||||||||
| Practice Location | |||||||||
| Address1: | 3635 BIENVILLE BLVD | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395645711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288721951 | ||||||||
| FaxNumber: | 2288759998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2016 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 901455 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 364SA2100X | 901455 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care | 364SA2200X | 901455 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 364SC0200X | 901455 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Critical Care Medicine | 364SG0600X | 901455 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 625905 | 05 | MS | MEDICAID |