Provider Demographics
NPI:1295828879
Name:BRENNAN, KEVIN FRANCIS (FNP-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:FRANCIS
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:F
Other - Last Name:BRENNAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:RED LAKE HOSPITAL
Mailing Address - Street 2:PO BOX 497, HIGHWAY 1
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:
Practice Address - Street 1:218 STONE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-782-7400
Practice Address - Fax:315-782-7460
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32 320050363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK807OtherSTATE LICENSE