Provider Demographics
NPI:1437698677
Name:MEMOLE, BRENNA JEAN (AGNP-C)
Entity Type:Individual
Prefix:MS
First Name:BRENNA
Middle Name:JEAN
Last Name:MEMOLE
Suffix:
Gender:F
Credentials:AGNP-C
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Mailing Address - Street 1:5998 ALCALA PARK
Mailing Address - Street 2:STUDENT HEALTH CENTER, MAHER HALL 140
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2492
Mailing Address - Country:US
Mailing Address - Phone:619-260-4595
Mailing Address - Fax:610-260-2375
Practice Address - Street 1:5998 ALCALA PARK
Practice Address - Street 2:STUDENT HEALTH CENTER, MAHER HALL 140
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2492
Practice Address - Country:US
Practice Address - Phone:619-260-4595
Practice Address - Fax:610-260-2375
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2020-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY716775163W00000X
CA95008681363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology