Provider Demographics
NPI:1326033457
Name:BRANNON, REGINA (NP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:BRANNON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:10 DAVOL SQ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4754
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:75 SOCKANOSSET CROSS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-5558
Practice Address - Country:US
Practice Address - Phone:401-946-6200
Practice Address - Fax:401-275-1992
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2013-09-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
RINPP13640363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI709004045OtherGROUP MEDICARE
RI9002852Medicaid
RI9002852Medicaid
RI9002852Medicaid