Provider Demographics
NPI:1417318783
Name:BRENNER, JUSTINA LEE (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:LEE
Last Name:BRENNER
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6137 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9788
Mailing Address - Country:US
Mailing Address - Phone:517-282-4399
Mailing Address - Fax:
Practice Address - Street 1:6137 GREEN RD
Practice Address - Street 2:
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-9788
Practice Address - Country:US
Practice Address - Phone:517-282-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704140572163WL0100X
MIL-17999163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant