Provider Demographics
NPI:1598397564
Name:MERRETT, BREON LATONIA (HOME HEALTH)
Entity Type:Individual
Prefix:
First Name:BREON
Middle Name:LATONIA
Last Name:MERRETT
Suffix:
Gender:F
Credentials:HOME HEALTH
Other - Prefix:
Other - First Name:BREON
Other - Middle Name:LATONIA
Other - Last Name:MERRETTCOOK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMA
Mailing Address - Street 1:3920 BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-3635
Mailing Address - Country:US
Mailing Address - Phone:515-803-4041
Mailing Address - Fax:515-279-0920
Practice Address - Street 1:3920 BEAVER AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-3635
Practice Address - Country:US
Practice Address - Phone:515-803-4041
Practice Address - Fax:515-279-0920
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1211Medicaid