Provider Demographics
NPI:1790263846
Name:TROTTER, BREAUNA C
Entity Type:Individual
Prefix:
First Name:BREAUNA
Middle Name:C
Last Name:TROTTER
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 1:501 ROSSMOYNE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-8614
Mailing Address - Country:US
Mailing Address - Phone:702-591-1231
Mailing Address - Fax:
Practice Address - Street 1:501 ROSSMOYNE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-8614
Practice Address - Country:US
Practice Address - Phone:702-591-1231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1401710699171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor