Provider Demographics
NPI:1407209703
Name:HALLER, BREANNE ROSE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:BREANNE
Middle Name:ROSE
Last Name:HALLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MISS
Other - First Name:BREANNE
Other - Middle Name:ROSE
Other - Last Name:HUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1310 W 22ND ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1501
Mailing Address - Country:US
Mailing Address - Phone:605-328-8200
Mailing Address - Fax:
Practice Address - Street 1:1310 W 22ND ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1501
Practice Address - Country:US
Practice Address - Phone:605-328-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001090363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily