Provider Demographics
NPI:1417539057
Name:THOMALLA, BRIANNA LEIGH (CNP)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:LEIGH
Last Name:THOMALLA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4902 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55319-9793
Mailing Address - Country:US
Mailing Address - Phone:132-033-3610
Mailing Address - Fax:
Practice Address - Street 1:4902 115TH AVE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55319-9793
Practice Address - Country:US
Practice Address - Phone:320-333-6109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8026363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health