Provider Demographics
NPI:1790240463
Name:STEPHENS, BREANNA (CBD)
Entity Type:Individual
Prefix:MRS
First Name:BREANNA
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:CBD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4063 COLUMBUS ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-6202
Mailing Address - Country:US
Mailing Address - Phone:541-619-2333
Mailing Address - Fax:
Practice Address - Street 1:4063 COLUMBUS ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6202
Practice Address - Country:US
Practice Address - Phone:541-619-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000003384374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000003384OtherTRADITIONAL HEALTH WORKER