Provider Demographics
NPI:1538879366
Name:BURNOM, BREONKA (MS, MAT)
Entity type:Individual
Prefix:
First Name:BREONKA
Middle Name:
Last Name:BURNOM
Suffix:
Gender:F
Credentials:MS, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 CRESWELL AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4774
Mailing Address - Country:US
Mailing Address - Phone:318-869-1899
Mailing Address - Fax:
Practice Address - Street 1:1519 CRESWELL AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4774
Practice Address - Country:US
Practice Address - Phone:318-869-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator