Healthcare Provider Details

I. General information

NPI: 1003204835
Provider Name (Legal Business Name): BRIANNA ALEXANDRIA HENDRA M.S., A.T., A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2015
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18601 MIDDLEBELT RD
ROMULUS MI
48174-9290
US

IV. Provider business mailing address

998 E FOREST AVE
YPSILANTI MI
48198-3877
US

V. Phone/Fax

Practice location:
  • Phone: 661-753-6579
  • Fax:
Mailing address:
  • Phone: 661-753-6579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.004820
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001390
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: