Provider Demographics
NPI:1407388721
Name:BRENNER, TATYANNA
Entity Type:Individual
Prefix:
First Name:TATYANNA
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10429 S 51ST ST
Mailing Address - Street 2:STE 207
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-5228
Mailing Address - Country:US
Mailing Address - Phone:480-326-2684
Mailing Address - Fax:
Practice Address - Street 1:10429 S 51ST ST
Practice Address - Street 2:STE 207
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-5228
Practice Address - Country:US
Practice Address - Phone:480-326-2684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-13125225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist