Provider Demographics
NPI:1114350329
Name:THREADGILL, BRITTANEE NICOLE
Entity Type:Individual
Prefix:
First Name:BRITTANEE
Middle Name:NICOLE
Last Name:THREADGILL
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 1:12009 CALLE SOMBRA APT 12
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7028
Mailing Address - Country:US
Mailing Address - Phone:951-385-3453
Mailing Address - Fax:
Practice Address - Street 1:22445 ALESSANDRO BLVD # 113-114
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8358
Practice Address - Country:US
Practice Address - Phone:951-924-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor