Provider Demographics
NPI:1396789509
Name:BRENNAN, MARY L (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9726
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-9726
Mailing Address - Country:US
Mailing Address - Phone:309-671-8749
Mailing Address - Fax:309-671-8740
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 119
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-1700
Practice Address - Fax:309-692-1771
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP82859Medicare UPIN