Provider Demographics
NPI:1275159428
Name:EVERT, BREANNA
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:EVERT
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 1:6155 GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1651
Mailing Address - Country:US
Mailing Address - Phone:224-271-6700
Mailing Address - Fax:224-271-6701
Practice Address - Street 1:6155 GRAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1651
Practice Address - Country:US
Practice Address - Phone:224-271-6700
Practice Address - Fax:224-271-6701
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008630363A00000X
WI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant