Provider Demographics
NPI:1194478974
Name:BALLARD, BRIANNA LEE
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:LEE
Last Name:BALLARD
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 1:3535 GALLAGHER RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527-4740
Mailing Address - Country:US
Mailing Address - Phone:603-733-8222
Mailing Address - Fax:
Practice Address - Street 1:3535 GALLAGHER RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-4740
Practice Address - Country:US
Practice Address - Phone:603-733-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9463460163W00000X
FLAPRN11019682367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse