Healthcare Provider Details

I. General information

NPI: 1760953384
Provider Name (Legal Business Name): NICOLE RENEE BREESNEE CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2308 W. 3RD AVE
SPOKANE WA
99201
US

IV. Provider business mailing address

12715 E MISSION AVE
SPOKANE VALLEY WA
99216-1027
US

V. Phone/Fax

Practice location:
  • Phone: 509-624-1244
  • Fax: 509-624-6240
Mailing address:
  • Phone: 509-232-5766
  • Fax: 509-321-5472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCO60709233
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: