Basic Information
Provider Information | |||||||||
NPI: | 1912194895 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LANDAU | ||||||||
FirstName: | BRENDA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 60447 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282600447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043162050 | ||||||||
FaxNumber: | 7043162051 | ||||||||
Practice Location | |||||||||
Address1: | 16525 HOLLY CREST LN STE 150 | ||||||||
Address2: |   | ||||||||
City: | HUNTERSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 280784911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043848720 | ||||||||
FaxNumber: | 7043848747 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2007 | ||||||||
LastUpdateDate: | 02/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0050-03522 | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5003522 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 7005483 | 05 | NC |   | MEDICAID |