Provider Demographics
NPI:1508287590
Name:HARRIS, BREANNA (MD)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 STATE HIGHWAY 22 W
Mailing Address - Street 2:
Mailing Address - City:DARDANELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72834-2907
Mailing Address - Country:US
Mailing Address - Phone:479-477-3084
Mailing Address - Fax:479-477-3098
Practice Address - Street 1:1714 STATE HIGHWAY 22 W
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834-2907
Practice Address - Country:US
Practice Address - Phone:479-477-3084
Practice Address - Fax:479-477-3098
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-17639207Q00000X
171M00000X
TXU1681208D00000X
TXBP10075205390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program