Basic Information
| Provider Information | |||||||||
| NPI: | 1609462514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALENTINE | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1906 EAGLE DR | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604506843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153424455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1715 N DIVISION ST STE 4D5E | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604503100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154313410 | ||||||||
| FaxNumber: | 8154313411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2020 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209.022238 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.