Provider Demographics
NPI:1538651526
Name:NOLAN, BREANNA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:NICOLE
Last Name:NOLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 UNIVERSITY TOWN CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-2421
Mailing Address - Country:US
Mailing Address - Phone:304-598-4835
Mailing Address - Fax:304-285-7388
Practice Address - Street 1:116 MATTHEW DR UNIT 100
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-8418
Practice Address - Country:US
Practice Address - Phone:724-439-4479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD474522208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program