Provider Demographics
NPI:1790019040
Name:BRENNER, KELLY EVELYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:EVELYN
Last Name:BRENNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:EVELYN
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:23845 HOLMAN HWY STE 203
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-5901
Mailing Address - Country:US
Mailing Address - Phone:831-241-9155
Mailing Address - Fax:831-241-9156
Practice Address - Street 1:23845 HOLMAN HWY STE 203
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940
Practice Address - Country:US
Practice Address - Phone:831-241-9155
Practice Address - Fax:831-241-9156
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA3854363A00000X
CA56134363A00000X
PAMA062568363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA3854OtherMASSACHUSETTS REGISTRATION
RIPA570OtherRI LICENSE