Provider Demographics
NPI:1669155826
Name:BALDWIN, BREONNA LYNN
Entity type:Individual
Prefix:
First Name:BREONNA
Middle Name:LYNN
Last Name:BALDWIN
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 1:1902 GLENWICK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-1411
Mailing Address - Country:US
Mailing Address - Phone:910-261-2593
Mailing Address - Fax:
Practice Address - Street 1:1902 GLENWICK DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-1411
Practice Address - Country:US
Practice Address - Phone:910-261-2593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH8426224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty