Provider Demographics
NPI:1740997659
Name:POGUE, BREANNA DANIELLE
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:DANIELLE
Last Name:POGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4767 LITTLE RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-3201
Mailing Address - Country:US
Mailing Address - Phone:937-789-0884
Mailing Address - Fax:
Practice Address - Street 1:4767 LITTLE RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-3201
Practice Address - Country:US
Practice Address - Phone:937-789-0884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH602317750321374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide