Provider Demographics
NPI:1538103437
Name:DRENNEN, MARY K (APN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:DRENNEN
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 1:9822 TAPESTRY PARK CIR STE 208
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-9260
Mailing Address - Country:US
Mailing Address - Phone:904-862-7200
Mailing Address - Fax:
Practice Address - Street 1:2106 NEW RD STE F2
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1053
Practice Address - Country:US
Practice Address - Phone:609-926-5451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN05109500363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7472803Medicaid
NJ7472803Medicaid
NJ381020OtherGROUP MEDICARE
NJS45708Medicare UPIN
NJ002893ZK8MMedicare PIN