Healthcare Provider Details

I. General information

NPI: 1578480216
Provider Name (Legal Business Name): BRYONNA MAE CANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 UTAH AVE BUILDING 744 FORT POLK
APO AA
71459
US

IV. Provider business mailing address

7600 UTAH AVE BLDG 744 FORT POLK
APO AA
71459
US

V. Phone/Fax

Practice location:
  • Phone: 337-302-5923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1604471
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: