Provider Demographics
NPI:1265850713
Name:BREATHE, TY JAYNE (RN)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:JAYNE
Last Name:BREATHE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:RUSSEL
Other - Last Name:LOHSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:503 PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1639
Mailing Address - Country:US
Mailing Address - Phone:415-424-2491
Mailing Address - Fax:
Practice Address - Street 1:818 CENTER STREET
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607
Practice Address - Country:US
Practice Address - Phone:415-424-2491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA826596163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse