Provider Demographics
NPI:1699179622
Name:SYRON, BRIANNA
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:SYRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2371 NE STEPHENS ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1372
Mailing Address - Country:US
Mailing Address - Phone:541-672-8533
Mailing Address - Fax:541-492-5217
Practice Address - Street 1:2371 NE STEPHENS ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1372
Practice Address - Country:US
Practice Address - Phone:541-672-8533
Practice Address - Fax:541-492-5217
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10165972133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165772Medicaid