Provider Demographics
NPI:1497257588
Name:GRIFFIN, BREANNA MICHELLE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:MICHELLE
Last Name:GRIFFIN
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 1:505 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PARK HILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63601-4215
Mailing Address - Country:US
Mailing Address - Phone:573-854-0053
Mailing Address - Fax:
Practice Address - Street 1:1025 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PARK HILLS
Practice Address - State:MO
Practice Address - Zip Code:63601-2079
Practice Address - Country:US
Practice Address - Phone:573-854-0053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018006930133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered