Provider Demographics
NPI:1124630629
Name:PRINCE, BREONA (LPN)
Entity type:Individual
Prefix:
First Name:BREONA
Middle Name:
Last Name:PRINCE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16970 LIBBY RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-1310
Mailing Address - Country:US
Mailing Address - Phone:216-965-3413
Mailing Address - Fax:
Practice Address - Street 1:16970 LIBBY RD
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-1310
Practice Address - Country:US
Practice Address - Phone:216-413-0131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174587.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse