Provider Demographics
NPI:1053731539
Name:BRANTLEY, CRYSTAL
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-0091
Mailing Address - Country:US
Mailing Address - Phone:614-378-7055
Mailing Address - Fax:
Practice Address - Street 1:170 GLACE RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-4628
Practice Address - Country:US
Practice Address - Phone:404-503-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14017845343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)