Healthcare Provider Details

I. General information

NPI: 1609584010
Provider Name (Legal Business Name): BREATNEY CHARLES INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5022 CAMPBELL BLVD STE L-M
NOTTINGHAM MD
21236-4969
US

IV. Provider business mailing address

5022 CAMPBELL BLVD STE L-M
NOTTINGHAM MD
21236-4969
US

V. Phone/Fax

Practice location:
  • Phone: 443-442-1568
  • Fax:
Mailing address:
  • Phone: 443-442-1568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: