Basic Information
| Provider Information | |||||||||
| NPI: | 1861485872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986327154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1405 DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142332 | ||||||||
| FaxNumber: | 3604142330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN00061070 | WA | X | Nursing Service Providers | Registered Nurse | 163WX0106X | RN00061070 | WA | X | Nursing Service Providers | Registered Nurse | Occupational Health | 363LA2200X | AP30001951 | WA | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LX0106X | AP30001951 | WA | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Occupational Health |
ID Information
| ID | Type | State | Issuer | Description | 100229 | 05 | OR | MEDICAID | 166678 | 01 | WA | LABOR & IND. | OTHER | 8933453 | 01 | WA | CRIME VICTIMS | OTHER | 9636150 | 05 | WA | MEDICAID |