Provider Demographics
NPI:1427694736
Name:PINK, BREANNE
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:PINK
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 1:855 A AVE NE STE 120
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5062
Mailing Address - Country:US
Mailing Address - Phone:319-297-9350
Mailing Address - Fax:319-297-9349
Practice Address - Street 1:855 A AVE NE STE 120
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5062
Practice Address - Country:US
Practice Address - Phone:319-297-9350
Practice Address - Fax:319-297-9349
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA157447363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily