Provider Demographics
NPI:1578752614
Name:BECKER, BRENNA W (NP)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:W
Last Name:BECKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BRENNA
Other - Middle Name:W
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2738 E PEBBLE GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3047
Mailing Address - Country:US
Mailing Address - Phone:508-864-5012
Mailing Address - Fax:
Practice Address - Street 1:675 S ARAPEEN DR # DR205
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1223
Practice Address - Country:US
Practice Address - Phone:801-581-3834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN266912363L00000X
UT9811085-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0723673Medicaid
MA0723673Medicaid