Healthcare Provider Details

I. General information

NPI: 1225572951
Provider Name (Legal Business Name): BREANNE STANBROUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNE CRUDELE

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 26TH ST
OGDEN UT
84401-3105
US

IV. Provider business mailing address

237 26TH ST
OGDEN UT
84401-3105
US

V. Phone/Fax

Practice location:
  • Phone: 801-625-3700
  • Fax:
Mailing address:
  • Phone: 801-625-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: