Provider Demographics
NPI:1568130979
Name:BRENNY, SAMANTHA MARIA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIA
Last Name:BRENNY
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 1:1352 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1420
Mailing Address - Country:US
Mailing Address - Phone:408-607-5887
Mailing Address - Fax:
Practice Address - Street 1:1352 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1420
Practice Address - Country:US
Practice Address - Phone:408-607-5887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer