Provider Demographics
NPI:1629400734
Name:CARMODY, BRENNAN N (NP)
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:N
Last Name:CARMODY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 N LINDER RD STE 103
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-3395
Mailing Address - Country:US
Mailing Address - Phone:208-565-0978
Mailing Address - Fax:
Practice Address - Street 1:943 N LINDER RD STE 103
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-3395
Practice Address - Country:US
Practice Address - Phone:208-565-0978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNPPEND363LX0001X
IDNP1318A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8937328OtherMEDICARE
WA0338594OtherL&I