Provider Demographics
NPI:1184129009
Name:FELLINGER, BREANA LEIGH (DO)
Entity type:Individual
Prefix:
First Name:BREANA
Middle Name:LEIGH
Last Name:FELLINGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 ALGOMA ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2104
Mailing Address - Country:US
Mailing Address - Phone:920-982-8300
Mailing Address - Fax:
Practice Address - Street 1:1420 ALGOMA ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2104
Practice Address - Country:US
Practice Address - Phone:920-982-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-25
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI73457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program