Provider Demographics
NPI:1538185848
Name:THEILEN, BRENDA MICHELLE (ANP)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:MICHELLE
Last Name:THEILEN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:MICHELLE
Other - Last Name:THEILEN-BLANKENSHIP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANP
Mailing Address - Street 1:21 CHESTERTON CT
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-7332
Mailing Address - Country:US
Mailing Address - Phone:843-949-8388
Mailing Address - Fax:
Practice Address - Street 1:21 CHESTERTON CT
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-7332
Practice Address - Country:US
Practice Address - Phone:843-949-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17635A363L00000X
GARN229112363L00000X
MO135188363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner