Healthcare Provider Details

I. General information

NPI: 1265260178
Provider Name (Legal Business Name): BREANNA MARIE BIEVENUE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 1ST ST E
STANTON TN
38069-4426
US

IV. Provider business mailing address

178 STEPHANIE ST
MILLINGTON TN
38053-5520
US

V. Phone/Fax

Practice location:
  • Phone: 731-548-2232
  • Fax:
Mailing address:
  • Phone: 618-521-4094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number36712
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: