Provider Demographics
NPI:1851139604
Name:BLACK, BREANA WHITTEN (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:BREANA
Middle Name:WHITTEN
Last Name:BLACK
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 HORTON DR
Mailing Address - Street 2:
Mailing Address - City:ODENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35120-3845
Mailing Address - Country:US
Mailing Address - Phone:813-777-5691
Mailing Address - Fax:
Practice Address - Street 1:3690 GRANDVIEW PKWY DEPT OF
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-3326
Practice Address - Country:US
Practice Address - Phone:205-971-7651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-169032363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty