MEDICARE: MRS. DANA THEIS BREAZEALE FNP

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	363LF0000X	Family Nurse Practitioner	APN 862	SC
2	363LF0000X	Family Nurse Practitioner	RN268214-COA08862	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992777932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANA THEIS BREAZEALE FNP

Provider Business Mailing Address
First Line	:	1344 CUSTER AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45208-2525
Country	:	US
Telephone Number	:	513-699-0833
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 VINE STREET
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45208
Country	:	US
Telephone Number	:	513-861-3100
Fax Number	:

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	07/09/2007

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