Provider Demographics
NPI:1497422885
Name:MINGO, BRIEONNA DAWN (MOTR/L)
Entity Type:Individual
Prefix:
First Name:BRIEONNA
Middle Name:DAWN
Last Name:MINGO
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:BRIEONNA
Other - Middle Name:DAWN
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1110 CALL CREEK DR STE 7
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3072
Mailing Address - Country:US
Mailing Address - Phone:208-233-4660
Mailing Address - Fax:208-233-4262
Practice Address - Street 1:1110 CALL CREEK DR STE 7
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3072
Practice Address - Country:US
Practice Address - Phone:208-233-4660
Practice Address - Fax:208-233-4262
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2415225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics