Healthcare Provider Details

I. General information

NPI: 1346179389
Provider Name (Legal Business Name): BREANNA NAKAMURA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11811 N TATUM BLVD STE 3031
PHOENIX AZ
85028-1621
US

IV. Provider business mailing address

17910 E SANOQUE BLVD
GILBERT AZ
85298-9220
US

V. Phone/Fax

Practice location:
  • Phone: 602-456-2936
  • Fax:
Mailing address:
  • Phone: 808-366-4035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA17234
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: