Provider Demographics
NPI:1639930670
Name:DENT, BREAUNA LATRICE (CNA)
Entity Type:Individual
Prefix:
First Name:BREAUNA
Middle Name:LATRICE
Last Name:DENT
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 N 73RD ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-1713
Mailing Address - Country:US
Mailing Address - Phone:618-514-2064
Mailing Address - Fax:
Practice Address - Street 1:837 N 73RD ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-1713
Practice Address - Country:US
Practice Address - Phone:618-514-2064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO147827376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide