Healthcare Provider Details

I. General information

NPI: 1275057358
Provider Name (Legal Business Name): BREANNE MILES AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 05/06/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 EAST HWY 243
CANTON TX
75103
US

IV. Provider business mailing address

PO BOX 931
CANTON TX
75103-0931
US

V. Phone/Fax

Practice location:
  • Phone: 903-567-4784
  • Fax: 903-567-4996
Mailing address:
  • Phone: 903-253-1203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP134573
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: