1356644025 NPI number — BRENDA ELLEN KENTNER RN, WCC

Table of content: BRENDA ELLEN KENTNER RN, WCC (NPI 1356644025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356644025 NPI number — BRENDA ELLEN KENTNER RN, WCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENTNER
Provider First Name:
BRENDA
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, WCC
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:
1356644025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
682 LANCASTER LANE
Provider Second Line Business Mailing Address:
PO BX 663
Provider Business Mailing Address City Name:
AFTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-449-0141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
682 LANCASTER LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AFTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-449-0141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2010

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: 163WW0000X , with the licence number:  28304 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4140801 . This is a "NATIONAL ALLIANCE OF WOUND CARE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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