Provider Demographics
NPI:1871678110
Name:BRENS, FATIMA A (MD)
Entity Type:Individual
Prefix:
First Name:FATIMA
Middle Name:A
Last Name:BRENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NC
Mailing Address - Zip Code:28164-1438
Mailing Address - Country:US
Mailing Address - Phone:704-263-8945
Mailing Address - Fax:704-263-2591
Practice Address - Street 1:700 N MAIN ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NC
Practice Address - Zip Code:28164
Practice Address - Country:US
Practice Address - Phone:704-263-8945
Practice Address - Fax:704-263-2591
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-01670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1871678110Medicaid
SCNO1671Medicaid
NC2044022Medicare Oscar/Certification