Provider Demographics
NPI:1518500917
Name:MERRIAM, BREANNA MAE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:MAE
Last Name:MERRIAM
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 1:12275 16TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-1773
Mailing Address - Country:US
Mailing Address - Phone:951-805-6107
Mailing Address - Fax:
Practice Address - Street 1:12275 16TH ST APT C
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-1773
Practice Address - Country:US
Practice Address - Phone:951-805-6107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA700747164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse