Provider Demographics
NPI:1053972281
Name:HOLLAND, BREONNA ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:BREONNA
Middle Name:ELIZABETH
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BREONNA
Other - Middle Name:ELIZABETH
Other - Last Name:BOST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-1229
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:3702 WASHINGTON ST STE 303
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8287
Practice Address - Country:US
Practice Address - Phone:954-518-2424
Practice Address - Fax:954-981-3476
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME163853208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119691800Medicaid