Provider Demographics
NPI:1033992912
Name:BARRY, BREANNA NICOLE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:NICOLE
Last Name:BARRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:NICOLE
Other - Last Name:BARRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1400 X ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-2200
Mailing Address - Country:US
Mailing Address - Phone:279-786-1457
Mailing Address - Fax:
Practice Address - Street 1:1400 X ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-2200
Practice Address - Country:US
Practice Address - Phone:279-786-1457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker