Provider Demographics
NPI:1649980269
Name:THOMAS, BREUNNA JA'MYREA
Entity type:Individual
Prefix:MS
First Name:BREUNNA
Middle Name:JA'MYREA
Last Name:THOMAS
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 1:1443 PRO SHOP CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8301
Mailing Address - Country:US
Mailing Address - Phone:407-988-7914
Mailing Address - Fax:
Practice Address - Street 1:1443 PRO SHOP CT
Practice Address - Street 2:
Practice Address - City:CHAMPIONS GATE
Practice Address - State:FL
Practice Address - Zip Code:33896-8301
Practice Address - Country:US
Practice Address - Phone:407-988-7914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL92-0843535Medicaid