Provider Demographics
NPI:1639375678
Name:ENGLE, BRENDA J (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:ENGLE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4506 CHANCERY LN
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-7707
Mailing Address - Country:US
Mailing Address - Phone:978-870-9324
Mailing Address - Fax:
Practice Address - Street 1:201 W LAKEWAY RD STE 311
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6306
Practice Address - Country:US
Practice Address - Phone:307-363-5930
Practice Address - Fax:888-720-0569
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA256189163W00000X
AZ231322163W00000X, 363LP0808X
WY388521580163WP0809X
MARN256189363LP0808X
WY1580363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110077041BMedicaid