Basic Information
| Provider Information | |||||||||
| NPI: | 1205401536 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SELF | ||||||||
| FirstName: | BRANDY | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655727 | ||||||||
| FaxNumber: | 2257654278 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 TOWER DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3199666320 | ||||||||
| FaxNumber: | 3189666321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2021 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 214453 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 214453 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.