Provider Demographics
NPI:1891902086
Name:NENNER, MITCHEL BRENT (LAC)
Entity Type:Individual
Prefix:MR
First Name:MITCHEL
Middle Name:BRENT
Last Name:NENNER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 W END AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-2723
Mailing Address - Country:US
Mailing Address - Phone:646-872-5514
Mailing Address - Fax:
Practice Address - Street 1:345 E 94TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-5684
Practice Address - Country:US
Practice Address - Phone:646-872-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001737171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist