Provider Demographics
NPI:1548045263
Name:DEWALT, BREYOCHA (NP)
Entity type:Individual
Prefix:
First Name:BREYOCHA
Middle Name:
Last Name:DEWALT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BREYOCHA
Other - Middle Name:
Other - Last Name:MAYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000, DEPT 960
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-758-9900
Mailing Address - Fax:901-752-2335
Practice Address - Street 1:1211 UNION AVE STE 965
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6638
Practice Address - Country:US
Practice Address - Phone:901-435-8550
Practice Address - Fax:901-478-0781
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000223825163WC0200X
TN34590363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine