Healthcare Provider Details

I. General information

NPI: 1669091393
Provider Name (Legal Business Name): BREANNA BELLE SO LAO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 10/15/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 N BROADWAY
ESCONDIDO CA
92025-1870
US

IV. Provider business mailing address

732 N BROADWAY
ESCONDIDO CA
92025-1870
US

V. Phone/Fax

Practice location:
  • Phone: 833-574-2273
  • Fax:
Mailing address:
  • Phone: 833-574-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA194151
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: