Basic Information
Provider Information | |||||||||
NPI: | 1295709830 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRANDT | ||||||||
FirstName: | CAROLYN | ||||||||
MiddleName: | JOY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.N., BSN, CCRC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHAMBERLIN | ||||||||
OtherFirstName: | CAROLYN | ||||||||
OtherMiddleName: | JOY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | R.N., BSN, CCRC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 34800 BOB WILSON DR | ||||||||
Address2: | NMCSD, ATTN: MEDICAL STAFF SERVICES | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921341098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195326460 | ||||||||
FaxNumber: | 6195326299 | ||||||||
Practice Location | |||||||||
Address1: | 34800 BOB WILSON DR | ||||||||
Address2: | NMCSD, ATTN: MEDICAL STAFF SERVICES | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921341098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195326460 | ||||||||
FaxNumber: | 6195326299 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N 264626 | CA | Y |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.