Basic Information
| Provider Information | |||||||||
| NPI: | 1639769797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS-GREEN | ||||||||
| FirstName: | BREANA | ||||||||
| MiddleName: | DIAMOND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 293 INDEPENDENCE BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234625461 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 293 INDEPENDENCE BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234625461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574903009 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2021 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | RBT-21-5226273256 | VA | Y | Agencies | Home Health |
No ID Information.