Provider Demographics
NPI:1568656015
Name:BRENNER, PENELOPE ANN (CRNA)
Entity Type:Individual
Prefix:MS
First Name:PENELOPE
Middle Name:ANN
Last Name:BRENNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2205
Mailing Address - Country:US
Mailing Address - Phone:318-747-3344
Mailing Address - Fax:
Practice Address - Street 1:520 GLENWOOD ST
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2205
Practice Address - Country:US
Practice Address - Phone:318-747-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN022405 AP01926163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1905348Medicaid