Provider Demographics
NPI:1245739903
Name:BROOKENS, BREANNA LEE
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:LEE
Last Name:BROOKENS
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 1:1531 BARNARD ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4902
Mailing Address - Country:US
Mailing Address - Phone:989-954-2391
Mailing Address - Fax:
Practice Address - Street 1:1531 BARNARD ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4902
Practice Address - Country:US
Practice Address - Phone:989-954-2391
Practice Address - Fax:989-954-2391
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIB625098497379208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid