Provider Demographics
NPI:1942261680
Name:BREEN, EILEEN (APRN BC)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:BREEN
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:TUTWILER
Mailing Address - State:MS
Mailing Address - Zip Code:38963-0297
Mailing Address - Country:US
Mailing Address - Phone:662-345-6217
Mailing Address - Fax:662-345-8336
Practice Address - Street 1:205 ALMA ST
Practice Address - Street 2:TUTWILER CLINIC
Practice Address - City:TUTWILER
Practice Address - State:MS
Practice Address - Zip Code:38913-0297
Practice Address - Country:US
Practice Address - Phone:662-345-8331
Practice Address - Fax:662-345-8336
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR767376363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114562Medicaid
506001327Medicare ID - Type Unspecified
MS00114562Medicaid