Provider Demographics
NPI:1578101762
Name:WING, BRIANNA (NP, RN)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:WING
Suffix:
Gender:F
Credentials:NP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9605 GRAND RONDE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RONDE
Mailing Address - State:OR
Mailing Address - Zip Code:97347-9712
Mailing Address - Country:US
Mailing Address - Phone:503-879-2002
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RONDE RD
Practice Address - Street 2:
Practice Address - City:GRAND RONDE
Practice Address - State:OR
Practice Address - Zip Code:97347-9712
Practice Address - Country:US
Practice Address - Phone:503-879-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2335343163W00000X
OR202112150NP-PP207Q00000X, 363LW0102X
WI10171-33363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10171-33OtherWISCONSIN BOARD OF NURSING
OR202112150NP-PPOtherOR STATE BOARD OF NURSING