Provider Demographics
NPI:1871662072
Name:BRENNAN, NOELLE (LPN)
Entity Type:Individual
Prefix:
First Name:NOELLE
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 W MILFORD DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2311
Mailing Address - Country:US
Mailing Address - Phone:315-437-5997
Mailing Address - Fax:
Practice Address - Street 1:156 W MILFORD DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-2311
Practice Address - Country:US
Practice Address - Phone:315-437-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262601-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02771319Medicaid