Provider Demographics
NPI:1376051995
Name:BRENNAN, KRISTY LEE (MS)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LEE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 MOON HILL RD
Mailing Address - Street 2:
Mailing Address - City:LAKE GEORGE
Mailing Address - State:NY
Mailing Address - Zip Code:12845-4506
Mailing Address - Country:US
Mailing Address - Phone:518-391-8196
Mailing Address - Fax:
Practice Address - Street 1:13 LOCUST ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4544
Practice Address - Country:US
Practice Address - Phone:518-761-2025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1794302174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist