1760243463 NPI number — BREEONA M WILKES RESIDENT IN COUNSELI

Table of content: BREEONA M WILKES RESIDENT IN COUNSELI (NPI 1760243463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760243463 NPI number — BREEONA M WILKES RESIDENT IN COUNSELI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKES
Provider First Name:
BREEONA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RESIDENT IN COUNSELI
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760243463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
739 THIMBLE SHOALS BLVD
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23606-3562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-838-1960
Provider Business Mailing Address Fax Number:
757-868-3280

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
348 MCLAWS CIRCLE
Provider Second Line Business Practice Location Address:
UNIT 1
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23185-6349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-838-1960
Provider Business Practice Location Address Fax Number:
757-838-3280
Provider Enumeration Date:
01/19/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0704016526 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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