Provider Demographics
NPI:1558447789
Name:BRENNAN, TERRIE JEAN (NP)
Entity Type:Individual
Prefix:MS
First Name:TERRIE
Middle Name:JEAN
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TERRIE
Other - Middle Name:JEAN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:160 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767
Mailing Address - Country:US
Mailing Address - Phone:631-484-0861
Mailing Address - Fax:631-361-8525
Practice Address - Street 1:285 SILLS RD BLDG 5-6
Practice Address - Street 2:SUITE A
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4869
Practice Address - Country:US
Practice Address - Phone:631-475-9300
Practice Address - Fax:631-475-6648
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303006363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q32266Medicare UPIN