Healthcare Provider Details

I. General information

NPI: 1427438829
Provider Name (Legal Business Name): BREANNA M DETRICK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BREANNA M TANLER CNP

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 OLENTANGY RIVER RD
COLUMBUS OH
43214-5404
US

IV. Provider business mailing address

PO BOX 7527
DUBLIN OH
43017-0727
US

V. Phone/Fax

Practice location:
  • Phone: 614-788-8334
  • Fax: 614-566-8489
Mailing address:
  • Phone: 614-788-8334
  • Fax: 614-566-8489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.17379
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.17379-NP
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.17379
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: