Basic Information
Provider Information | |||||||||
NPI: | 1144693979 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLETCHER | ||||||||
FirstName: | BRANDI | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ELLZEY | ||||||||
OtherFirstName: | BRANDI | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 507 | ||||||||
Address2: |   | ||||||||
City: | LOWELL | ||||||||
State: | AR | ||||||||
PostalCode: | 727450507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136474100 | ||||||||
FaxNumber: | 9136474120 | ||||||||
Practice Location | |||||||||
Address1: | 3101 SE 14TH STREET | ||||||||
Address2: |   | ||||||||
City: | BENTONVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727124900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4799866199 | ||||||||
FaxNumber: | 4796360371 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2015 | ||||||||
LastUpdateDate: | 01/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R099622 | AR | N |   | Nursing Service Providers | Registered Nurse |   | 363L00000X | 217410 | AR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.