Provider Demographics
NPI:1891500542
Name:KELLOGG, BREONNA (RN, COO)
Entity type:Individual
Prefix:
First Name:BREONNA
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:RN, COO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 S 96TH ST STE 134
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-1240
Mailing Address - Country:US
Mailing Address - Phone:402-714-2414
Mailing Address - Fax:402-607-8367
Practice Address - Street 1:4611 S 96TH ST STE 134
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-1240
Practice Address - Country:US
Practice Address - Phone:402-607-8344
Practice Address - Fax:402-607-8367
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9440338163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse