Provider Demographics
NPI:1659128338
Name:HENDERSHOT, BREANNA J
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:J
Last Name:HENDERSHOT
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:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:REDWAY
Mailing Address - State:CA
Mailing Address - Zip Code:95560-0696
Mailing Address - Country:US
Mailing Address - Phone:707-672-2168
Mailing Address - Fax:
Practice Address - Street 1:71 N SCOTIA CT
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:CA
Practice Address - Zip Code:95565
Practice Address - Country:US
Practice Address - Phone:707-672-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula