Provider Demographics
NPI:1073720751
Name:BRANDT, MARY ELLEN (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:BRANDT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 WOODBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4413
Mailing Address - Country:US
Mailing Address - Phone:651-487-5544
Mailing Address - Fax:
Practice Address - Street 1:1418 WOODBRIDGE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-4413
Practice Address - Country:US
Practice Address - Phone:651-487-5544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL 052191-6164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse