Provider Demographics
NPI:1174851497
Name:PETRO, BRENNA J (FNP)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:J
Last Name:PETRO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2199 N MERRIT CRK LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4949
Mailing Address - Country:US
Mailing Address - Phone:208-665-7546
Mailing Address - Fax:
Practice Address - Street 1:2199 N MERRIT CRK LOOP
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4949
Practice Address - Country:US
Practice Address - Phone:208-665-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN134782363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ488480Medicaid