Provider Demographics
NPI:1083205009
Name:SCOTT, BREANA TAKIA
Entity Type:Individual
Prefix:
First Name:BREANA
Middle Name:TAKIA
Last Name:SCOTT
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 1:16201 LAKE SHORE BLVD
Mailing Address - Street 2:APR 322
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110
Mailing Address - Country:US
Mailing Address - Phone:440-990-4822
Mailing Address - Fax:
Practice Address - Street 1:16201 LAKE SHORE BLVD
Practice Address - Street 2:APR 322
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110
Practice Address - Country:US
Practice Address - Phone:440-990-4822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000000Medicaid