Provider Demographics
NPI:1528083748
Name:FENNELL, BRANDEIS K (NP)
Entity type:Individual
Prefix:
First Name:BRANDEIS
Middle Name:K
Last Name:FENNELL
Suffix:
Gender:F
Credentials:NP
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-2564
Mailing Address - Fax:843-777-5135
Practice Address - Street 1:1203 EAST CHEVES STREET
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2711
Practice Address - Country:US
Practice Address - Phone:843-777-2564
Practice Address - Fax:843-777-5135
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2829363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1010Medicaid
SCAA14468552Medicare ID - Type Unspecified
SCNP1010Medicaid