Basic Information
| Provider Information | |||||||||
| NPI: | 1386216729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRINNER | ||||||||
| FirstName: | ANGEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 615 EE WALLACE BLVD S | ||||||||
| Address2: | |||||||||
| City: | FERRIDAY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713343224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187579363 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 615 EE WALLACE BLVD S | ||||||||
| Address2: | |||||||||
| City: | FERRIDAY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713343224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187479363 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2021 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.