Provider Demographics
NPI:1871062869
Name:BANDY, BRITTANY
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:BANDY
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 1:490 CENTRE LAKE DR NE STE 200B
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1189
Mailing Address - Country:US
Mailing Address - Phone:321-784-8211
Mailing Address - Fax:
Practice Address - Street 1:490 CENTRE LAKE DR NE STE 200B
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1189
Practice Address - Country:US
Practice Address - Phone:321-784-8211
Practice Address - Fax:321-394-9425
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115766363A00000X
LA310589363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA310589OtherPHYSICIAN ASSISTANT STATE LICENSE
FLPA9115766OtherPHYSICIAN ASSISTANT STATE LICENSE
1152714OtherPHYSICIAN ASSISTANT CERTIFICATION