Provider Demographics
NPI:1942671201
Name:BRENNER, KAITLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:DON
Other - Last Name:PROULX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-364-4999
Mailing Address - Fax:
Practice Address - Street 1:3500 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4491
Practice Address - Country:US
Practice Address - Phone:715-817-7100
Practice Address - Fax:715-817-7039
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7142363A00000X
MN2348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant