Provider Demographics
NPI:1750733408
Name:BREWER, RENETTA ELAINE (NP-C)
Entity type:Individual
Prefix:
First Name:RENETTA
Middle Name:ELAINE
Last Name:BREWER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:RENETTA
Other - Middle Name:ELAINE
Other - Last Name:DESKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4610 KANAWHA AVE SW
Mailing Address - Street 2:SUITE 402
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1367
Mailing Address - Country:US
Mailing Address - Phone:304-400-4700
Mailing Address - Fax:
Practice Address - Street 1:4610 KANAWHA AVE SW
Practice Address - Street 2:SUITE 402
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1367
Practice Address - Country:US
Practice Address - Phone:304-400-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN80717-NP-C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner