Provider Demographics
NPI:1437823127
Name:ANDERSON, BREANNA
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:ANDERSON
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 1:35B MATTINGLY AVE
Mailing Address - Street 2:
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640-1731
Mailing Address - Country:US
Mailing Address - Phone:240-419-8712
Mailing Address - Fax:
Practice Address - Street 1:35B MATTINGLY AVE
Practice Address - Street 2:
Practice Address - City:INDIAN HEAD
Practice Address - State:MD
Practice Address - Zip Code:20640-1731
Practice Address - Country:US
Practice Address - Phone:240-419-8712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00183232376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide