Basic Information
| Provider Information | |||||||||
| NPI: | 1760468383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JERNANDER | ||||||||
| FirstName: | BRANDI | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAMBO | ||||||||
| OtherFirstName: | BRANDI | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 222 PERRY HWY | ||||||||
| Address2: | BLDG A | ||||||||
| City: | HAWKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310366748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787834307 | ||||||||
| FaxNumber: | 4787834309 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PERRY HWY | ||||||||
| Address2: | BLDG A | ||||||||
| City: | HAWKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310366748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787834307 | ||||||||
| FaxNumber: | 4787834309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 02/12/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN149163 NP | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 432259684A | 05 | GA | MEDICAID | 432259684B | 05 | GA | MEDICAID |