Provider Demographics
NPI:1992777932
Name:BREAZEALE, DANA THEIS (FNP)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:THEIS
Last Name:BREAZEALE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 CUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45208-2525
Mailing Address - Country:US
Mailing Address - Phone:513-699-0833
Mailing Address - Fax:
Practice Address - Street 1:3200 VINE STREET
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45208
Practice Address - Country:US
Practice Address - Phone:513-861-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN 862363LF0000X
OHRN268214-COA08862363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0533Medicaid
SCNP0533Medicaid
SCP18921Medicare UPIN