Provider Demographics
NPI:1952059081
Name:BOGEN, BREANNE
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:BOGEN
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 1:1217 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70380-6035
Mailing Address - Country:US
Mailing Address - Phone:985-870-2294
Mailing Address - Fax:
Practice Address - Street 1:1217 JAMES ST
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-6035
Practice Address - Country:US
Practice Address - Phone:985-870-2294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty