1861485872 NPI number — MARY E BRENNAN ARNP

Table of content: MARY E BRENNAN ARNP (NPI 1861485872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861485872 NPI number — MARY E BRENNAN ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNAN
Provider First Name:
MARY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861485872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632-7154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-414-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 DELAWARE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-2326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-414-2332
Provider Business Practice Location Address Fax Number:
360-414-2330
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN00061070 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 163WX0106X , with the licence number: RN00061070 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LA2200X , with the licence number: AP30001951 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LX0106X , with the licence number: AP30001951 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100229 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166678 . This is a "LABOR & IND." identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8933453 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9636150 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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