Provider Demographics
NPI:1407456783
Name:CLEMENTS, BRENNA MICHELLE (FNP)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:MICHELLE
Last Name:CLEMENTS
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 1:1130 E MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2718
Mailing Address - Country:US
Mailing Address - Phone:602-283-4711
Mailing Address - Fax:602-671-4260
Practice Address - Street 1:1130 E MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2718
Practice Address - Country:US
Practice Address - Phone:602-283-4711
Practice Address - Fax:602-671-4260
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ249237363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
84-4869956OtherIRS