Provider Demographics
NPI:1518522788
Name:GARDELL, BRENNA SUZANNE
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:SUZANNE
Last Name:GARDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 N INTERSTATE HIGHWAY 35 E STE 225
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-5273
Mailing Address - Country:US
Mailing Address - Phone:469-800-9790
Mailing Address - Fax:
Practice Address - Street 1:2460 N INTERSTATE HIGHWAY 35 E STE 225
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5273
Practice Address - Country:US
Practice Address - Phone:469-800-9790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant