Provider Demographics
NPI:1336602382
Name:PATTON KANTENGA, BRESHA
Entity Type:Individual
Prefix:
First Name:BRESHA
Middle Name:
Last Name:PATTON KANTENGA
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 1:2318 SW WYNNEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2439
Mailing Address - Country:US
Mailing Address - Phone:772-333-2001
Mailing Address - Fax:
Practice Address - Street 1:2318 SW WYNNEWOOD ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2439
Practice Address - Country:US
Practice Address - Phone:772-333-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001383363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care