Provider Demographics
NPI:1184249633
Name:WASHINGTON, BREONA CHANEL
Entity type:Individual
Prefix:
First Name:BREONA
Middle Name:CHANEL
Last Name:WASHINGTON
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 1:6974 WALKER MILL RD APT A1
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743
Mailing Address - Country:US
Mailing Address - Phone:202-903-4579
Mailing Address - Fax:
Practice Address - Street 1:6974 WALKER MILL RD APT A1
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743
Practice Address - Country:US
Practice Address - Phone:202-903-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3646226172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3646226OtherDRIVER LICENSE