Provider Demographics
NPI:1154981850
Name:NIEHOFF, BRIANNA D (OD)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:D
Last Name:NIEHOFF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:D
Other - Last Name:KEENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2045 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-2921
Mailing Address - Country:US
Mailing Address - Phone:765-825-6000
Mailing Address - Fax:765-825-3075
Practice Address - Street 1:2045 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2921
Practice Address - Country:US
Practice Address - Phone:765-825-6000
Practice Address - Fax:765-825-3075
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004167A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300028108Medicaid