Basic Information
| Provider Information | |||||||||
| NPI: | 1043690894 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREW | ||||||||
| FirstName: | TANIELLE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042965691 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1760 EDGEWOOD AVE W STE A&B | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043588480 | ||||||||
| FaxNumber: | 9043588460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2015 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TRN 21895 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME129374 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.