Provider Demographics
NPI:1508398124
Name:BRENNER, MARIELLE ALYSSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIELLE
Middle Name:ALYSSA
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-353-6360
Mailing Address - Fax:319-353-7006
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-353-6360
Practice Address - Fax:319-353-7006
Is Sole Proprietor?:No
Enumeration Date:2017-04-02
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7025520207P00000X
IN01083722A207P00000X
IAMD-49363207PT0002X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300037013Medicaid