Provider Demographics
NPI:1598422578
Name:BLACK, BREONA LASHAWN (CNM)
Entity Type:Individual
Prefix:MS
First Name:BREONA
Middle Name:LASHAWN
Last Name:BLACK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 19TH ST SE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-7515
Mailing Address - Country:US
Mailing Address - Phone:903-491-6563
Mailing Address - Fax:
Practice Address - Street 1:6609 VIRGINIA PKWY
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-5513
Practice Address - Country:US
Practice Address - Phone:972-542-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-24
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1060449367A00000X
TX926806163WX0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient