Provider Demographics
NPI:1710355607
Name:BRENTA, MARCIA
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:BRENTA
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 1:579 HIDDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:95524-9049
Mailing Address - Country:US
Mailing Address - Phone:707-443-3557
Mailing Address - Fax:
Practice Address - Street 1:1930 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1406
Practice Address - Country:US
Practice Address - Phone:707-443-3557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262859363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology