Provider Demographics
NPI:1770025959
Name:DI DATO, BREA (FNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:BREA
Middle Name:
Last Name:DI DATO
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SW DISK DR STE 250
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3754
Mailing Address - Country:US
Mailing Address - Phone:541-293-1325
Mailing Address - Fax:541-229-1314
Practice Address - Street 1:1001 SW DISK DR STE 250
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3754
Practice Address - Country:US
Practice Address - Phone:541-293-1325
Practice Address - Fax:541-229-1314
Is Sole Proprietor?:No
Enumeration Date:2016-11-05
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201902570RN163W00000X
OR201906949NP-PP363LF0000X
OR202002414NP-PP363LP0808X
CA95005877363LF0000X
CA709645163W00000X
CANP95005877363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily