Provider Demographics
NPI:1306876099
Name:BAILEY, BREANN LYN (MD)
Entity type:Individual
Prefix:
First Name:BREANN
Middle Name:LYN
Last Name:BAILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 8TH ST
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-2426
Mailing Address - Country:US
Mailing Address - Phone:540-639-5188
Mailing Address - Fax:540-639-9215
Practice Address - Street 1:202 8TH ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-2426
Practice Address - Country:US
Practice Address - Phone:540-639-5188
Practice Address - Fax:540-639-9215
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2016-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27148208000000X
VA0101246067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC271486Medicaid
VA7123334OtherCIGNA
VA379826OtherANTHEM
SC576007863102OtherBCBS
VA7200954OtherAETNA
VA379826OtherANTHEM