Provider Demographics
NPI:1801570668
Name:BRANNAN, CAMERON RAE (LAT, ATC)
Entity type:Individual
Prefix:MRS
First Name:CAMERON
Middle Name:RAE
Last Name:BRANNAN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:MS
Other - First Name:CAMERON
Other - Middle Name:RAE
Other - Last Name:SIMKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:2346 E SYLVIA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-5857
Mailing Address - Country:US
Mailing Address - Phone:505-480-8632
Mailing Address - Fax:
Practice Address - Street 1:4701 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1723
Practice Address - Country:US
Practice Address - Phone:602-264-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-0093112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer