Provider Demographics
NPI:1083142749
Name:HAYES, BREANNA LEE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:LEE
Last Name:HAYES
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 1:134 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-2806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1572
Practice Address - Country:US
Practice Address - Phone:304-455-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002075225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant