Provider Demographics
NPI:1164179008
Name:MARSHALL, BREANNA NICOLE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:NICOLE
Last Name:MARSHALL
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 1:570 DEEPHOLE BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:WV
Mailing Address - Zip Code:25517-7701
Mailing Address - Country:US
Mailing Address - Phone:304-939-8226
Mailing Address - Fax:
Practice Address - Street 1:570 DEEPHOLE BRANCH RD
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:WV
Practice Address - Zip Code:25517-7701
Practice Address - Country:US
Practice Address - Phone:304-939-8226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant