Provider Demographics
NPI:1457092447
Name:BRENNER, MARA JORDEN (RN)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:JORDEN
Last Name:BRENNER
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:
Other - Last Name:ROETHLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:49 BIRCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36093-1776
Mailing Address - Country:US
Mailing Address - Phone:509-995-5229
Mailing Address - Fax:
Practice Address - Street 1:113 E BRIDGE ST STE D
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-2734
Practice Address - Country:US
Practice Address - Phone:334-782-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61044061163W00000X
STUDENT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No163W00000XNursing Service ProvidersRegistered Nurse