Provider Demographics
NPI:1467731976
Name:BREEDING, AVIAN DINAH (LPN)
Entity Type:Individual
Prefix:
First Name:AVIAN
Middle Name:DINAH
Last Name:BREEDING
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 EDGEMERE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071
Mailing Address - Country:US
Mailing Address - Phone:405-410-2367
Mailing Address - Fax:
Practice Address - Street 1:4149 HIGHLINE BLVD
Practice Address - Street 2:SUITE 380
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73108-2103
Practice Address - Country:US
Practice Address - Phone:405-942-7650
Practice Address - Fax:405-942-7686
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0059297164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid