Provider Demographics
NPI:1730195884
Name:BRENNER, LAURIE JEAN (BSN, WHNP-BC)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:JEAN
Last Name:BRENNER
Suffix:
Gender:F
Credentials:BSN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-2558
Mailing Address - Country:US
Mailing Address - Phone:989-752-1900
Mailing Address - Fax:989-752-1901
Practice Address - Street 1:1119 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-2558
Practice Address - Country:US
Practice Address - Phone:989-752-1900
Practice Address - Fax:989-752-1901
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704158768363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4380712Medicaid
MION46370Medicare ID - Type Unspecified