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General NPI Number Information
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NPI Number | 1780212175
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Entity Type | Individual
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Provider Name | BREANNA ELIZABETH FLACCAVENTO PA-C
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Gender | Female
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Dates
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Enumeration Date | 03/31/2020
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Last Update Date | 05/19/2025
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Provider Practice Location Address
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Address Line | 725 BOYETTE ROAD
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City | FOUR OAKS
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State | NC
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Zip | 27524
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Country | US
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Telephone | 877-935-5255
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Fax |
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Provider Business Mailing Address
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Address Line | 6114 US HIGHWAY 301 S
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City | FOUR OAKS
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State | NC
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Zip | 27524-7417
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Country | US
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Telephone | 814-460-4746
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-10537
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License Number State | NC
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