Provider Demographics
NPI:1427438829
Name:DETRICK, BREANNA M (CNP)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:M
Last Name:DETRICK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:M
Other - Last Name:TANLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:614-788-8334
Mailing Address - Fax:614-566-8489
Practice Address - Street 1:3830 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-5404
Practice Address - Country:US
Practice Address - Phone:614-788-8334
Practice Address - Fax:614-566-8489
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.17379-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH327940Medicare PIN