Basic Information
| Provider Information | |||||||||
| NPI: | 1558614461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAZZELL | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 TEKE BURTON DR | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474461208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128493408 | ||||||||
| FaxNumber: | 8128495630 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 TEKE BURTON DR | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474461208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128493408 | ||||||||
| FaxNumber: | 8128495630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 28151328 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 28151328A | 01 | IN | RN | OTHER | 71004232A | 01 | IN | FNP LICENSE # | OTHER | 71004232B | 01 | IN | CSR PRESCRIPTIVE AUTHORITY | OTHER |