Provider Demographics
NPI:1528253879
Name:BLACK, BRIANNE (RN)
Entity type:Individual
Prefix:
First Name:BRIANNE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:BRIANNE
Other - Middle Name:
Other - Last Name:REISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9959 DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-2632
Mailing Address - Country:US
Mailing Address - Phone:303-289-2790
Mailing Address - Fax:
Practice Address - Street 1:421 ZANG ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1052
Practice Address - Country:US
Practice Address - Phone:303-996-3844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0204402163W00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORN.0204402OtherSTATE OF COLO DEPT OF REGULATORY AGENCIES