Basic Information
| Provider Information | |||||||||
| NPI: | 1578101762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WING | ||||||||
| FirstName: | BRIANNA | ||||||||
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| Credential: | NP, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9605 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9605 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792002 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2019 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN2335343 | MA | N | Nursing Service Providers | Registered Nurse | 363LW0102X | 10171-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LW0102X | 202112150NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 10171-33 | 01 | WI | WISCONSIN BOARD OF NURSING | OTHER | 202112150NP-PP | 01 | OR | OR STATE BOARD OF NURSING | OTHER |