Basic Information
| Provider Information | |||||||||
| NPI: | 1396789509 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9726 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616129726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096718749 | ||||||||
| FaxNumber: | 3096718740 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 N KNOXVILLE AVE | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616145098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096921700 | ||||||||
| FaxNumber: | 3096921771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.