Basic Information
Provider Information | |||||||||
NPI: | 1932545472 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRANTLEY | ||||||||
FirstName: | GALE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRANTLEY | ||||||||
OtherFirstName: | MILDRED | ||||||||
OtherMiddleName: | GALE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2336 | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | AR | ||||||||
PostalCode: | 726542336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8704247070 | ||||||||
FaxNumber: | 8704246616 | ||||||||
Practice Location | |||||||||
Address1: | 624 HOSPITAL DRIVE | ||||||||
Address2: | DEPT 4610 | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | AR | ||||||||
PostalCode: | 726532955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8705081000 | ||||||||
FaxNumber: | 9545143979 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2013 | ||||||||
LastUpdateDate: | 03/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN1723702 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 124032 | AR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.