Provider Demographics
NPI:1649815440
Name:BRENNAN, KRISTI MCHALE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:MCHALE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:855-963-2100
Mailing Address - Fax:239-236-2775
Practice Address - Street 1:2514 E DUPONT RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1619
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10002894A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant