Provider Demographics
NPI:1619861382
Name:PHAN, BRENNEN (RN)
Entity type:Individual
Prefix:MR
First Name:BRENNEN
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 S PELICAN AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4747
Mailing Address - Country:US
Mailing Address - Phone:208-794-2175
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-706-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID73136163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse