Provider Demographics
NPI:1164756243
Name:TATE, BRENNA L (CNM)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:L
Last Name:TATE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:BRENNA
Other - Middle Name:L
Other - Last Name:SMALLFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1680 DIAGONAL RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1008
Practice Address - Country:US
Practice Address - Phone:507-372-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR192172-2367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN420000710Medicare PIN