1558665794 NPI number — MRS. ANDREA N BRENTLEY MS, RN, FNP-BC

Table of content: MRS. ANDREA N BRENTLEY MS, RN, FNP-BC (NPI 1558665794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558665794 NPI number — MRS. ANDREA N BRENTLEY MS, RN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENTLEY
Provider First Name:
ANDREA
Provider Middle Name:
N
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, RN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLEMAN
Provider Other First Name:
ANDREA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, BSN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558665794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
460 W 10TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43210-1240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-293-8619
Provider Business Mailing Address Fax Number:
614-293-6420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 W 10TH AVE
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43210-1240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-293-8619
Provider Business Practice Location Address Fax Number:
614-293-6420
Provider Enumeration Date:
01/03/2011

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: 363LA2200X , with the licence number:  COA.12955NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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