Basic Information
| Provider Information | |||||||||
| NPI: | 1023388865 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATZEN | ||||||||
| FirstName: | BREANA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CNM, ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1658 ST VINCENTS WAY | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | MIDDLEBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320688446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042641628 | ||||||||
| FaxNumber: | 9042648386 | ||||||||
| Practice Location | |||||||||
| Address1: | 1658 ST VINCENTS WAY | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | MIDDLEBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320688446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042641628 | ||||||||
| FaxNumber: | 9042648386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2012 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9287898 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | ARNP9287898 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LX0001X | ARNP9287898 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | Y09YP | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 004589600 | 05 | FL | MEDICAID |