Provider Demographics
NPI:1285216903
Name:HUDSON, BREANNA TARA
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:TARA
Last Name:HUDSON
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:PO BOX 1153
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-1153
Mailing Address - Country:US
Mailing Address - Phone:681-296-7052
Mailing Address - Fax:
Practice Address - Street 1:115 PINE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-5349
Practice Address - Country:US
Practice Address - Phone:681-296-7052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant