Basic Information
Provider Information | |||||||||
NPI: | 1699760884 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRANNON | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | ALEXIS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THOMAS | ||||||||
OtherFirstName: | LAURA | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 401 E ROBINSON ST | ||||||||
Address2: | UNIT 403 | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328014331 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073945223 | ||||||||
FaxNumber: | 8666454229 | ||||||||
Practice Location | |||||||||
Address1: | 1001 SAINT JOSEPH LN | ||||||||
Address2: |   | ||||||||
City: | LONDON | ||||||||
State: | KY | ||||||||
PostalCode: | 407418345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6063306000 | ||||||||
FaxNumber: | 6063307825 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2005 | ||||||||
LastUpdateDate: | 11/01/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP 451472 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | ARNP 0024165709 | VA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | ARNP 711364 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 3000063 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 305050900 | 05 | FL |   | MEDICAID | 02157 | 01 | FL | BLUE SHIELD | OTHER |