Basic Information
| Provider Information | |||||||||
| NPI: | 1417323213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAZELL JULIAN | ||||||||
| FirstName: | MATTIE | ||||||||
| MiddleName: | KRISTEN | ||||||||
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| Credential: | WHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PALMETTO HEALTH PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292121763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039077300 | ||||||||
| FaxNumber: | 8039077309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2015 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 19368 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | NP3400 | 05 | SC | MEDICAID |