MEDICARE: BREANNE MARTINA GRACE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0807X	Child & Adolescent Psychiatric/Mental Health Registered Nurse	RN.442129	OH

General Provider Information

NPI Number	:	1407707417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNE MARTINA GRACE RN

Provider Business Mailing Address
First Line	:	3849 W 162ND ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-4205
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3849 W 162ND ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-4205
Country	:	US
Telephone Number	:	330-907-4510
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2026
Last Update Date	:	02/05/2026

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