Provider Demographics
NPI:1164157145
Name:ELLEBRACHT, BRENDAN (RN)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:ELLEBRACHT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 WALTERS WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4651
Mailing Address - Country:US
Mailing Address - Phone:636-448-1580
Mailing Address - Fax:
Practice Address - Street 1:901 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65897-0027
Practice Address - Country:US
Practice Address - Phone:417-836-5039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO201803196163W00000X
MO2023025394367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse