Provider Demographics
NPI:1366100802
Name:BRANTLEY, EMILY WALLACE (NP)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:WALLACE
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:EMILY
Other - Middle Name:CLARK
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4374 NEW TOWN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2865
Mailing Address - Country:US
Mailing Address - Phone:757-984-6110
Mailing Address - Fax:
Practice Address - Street 1:4374 NEW TOWN AVE STE 200
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2865
Practice Address - Country:US
Practice Address - Phone:757-984-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024188752363LF0000X
VA0001270316163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse