Healthcare Provider Details

I. General information

NPI: 1912557372
Provider Name (Legal Business Name): BREANNA LEIGH DOENITZ ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNA LEIGH ROUNDTREE

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 02/24/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 OLD MARLTON PIKE WEST SUITE 1
MARLTON NJ
08053
US

IV. Provider business mailing address

401 ROUTE 73 N STE 320
MARLTON NJ
08053-3426
US

V. Phone/Fax

Practice location:
  • Phone: 856-988-9101
  • Fax:
Mailing address:
  • Phone: 856-988-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberTMP-158957
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number26NJ01231600
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number140609
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: