Provider Demographics
NPI:1568908929
Name:BANFORD, BREANN NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:BREANN
Middle Name:NICOLE
Last Name:BANFORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:BREANN
Other - Middle Name:NICOLE
Other - Last Name:ROWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:14688 S ASTIN LN # Q204
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-2245
Mailing Address - Country:US
Mailing Address - Phone:725-724-2310
Mailing Address - Fax:
Practice Address - Street 1:2055 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9819
Practice Address - Country:US
Practice Address - Phone:358-433-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7776134-4405363L00000X
UT7776134-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse