Provider Demographics
NPI:1740232230
Name:CLEMENS, BRENDA K (NP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:K
Last Name:CLEMENS
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 1:1326 MALABAR RD SE STE 3
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2502
Mailing Address - Country:US
Mailing Address - Phone:321-409-6100
Mailing Address - Fax:321-409-6063
Practice Address - Street 1:1326 MALABAR RD SE STE 3
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2502
Practice Address - Country:US
Practice Address - Phone:321-409-6100
Practice Address - Fax:321-409-6063
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2017-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71001942A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIT764ZOtherMEDICARE
IN259990028Medicare PIN
INQ50719Medicare UPIN