Basic Information
| Provider Information | |||||||||
| NPI: | 1659381127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANTLEY | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | HARRISON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3540 CRAIN HWY # 500 | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207161303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012622233 | ||||||||
| FaxNumber: | 2406861972 | ||||||||
| Practice Location | |||||||||
| Address1: | 3540 CRAIN HWY # 500 | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207161303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012622233 | ||||||||
| FaxNumber: | 2406861972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | D0054039 | MD | Y | Other Service Providers | Specialist |
No ID Information.