Provider Demographics
NPI:1922542661
Name:BRENNAN, KAITLEN IRENE (LAC)
Entity Type:Individual
Prefix:
First Name:KAITLEN
Middle Name:IRENE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3123
Mailing Address - Country:US
Mailing Address - Phone:651-206-8005
Mailing Address - Fax:
Practice Address - Street 1:1032 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3064
Practice Address - Country:US
Practice Address - Phone:651-227-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1790171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist