Provider Demographics
NPI:1407817422
Name:BRENENSTALL, DONNA J (APN)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:J
Last Name:BRENENSTALL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5091
Mailing Address - Country:US
Mailing Address - Phone:309-689-8477
Mailing Address - Fax:309-683-0201
Practice Address - Street 1:5401 N KNOXVILLE AVE STE 114
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5091
Practice Address - Country:US
Practice Address - Phone:309-689-8477
Practice Address - Fax:309-683-0201
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001128363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
309001107OtherCONT SUBS
209001128OtherAPN
041149492OtherRN
041149492OtherRN