Basic Information
| Provider Information | |||||||||
| NPI: | 1407527484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANTLEY | ||||||||
| FirstName: | ABIGAIL | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REESE | ||||||||
| OtherFirstName: | ABIGAIL | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS RDN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 401 VZ COUNTY ROAD 2518 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751033872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033303970 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 706 TURTLE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757011833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035953942 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2021 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.