Basic Information
| Provider Information | |||||||||
| NPI: | 1871678110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENS | ||||||||
| FirstName: | FATIMA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STANLEY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281641438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042638945 | ||||||||
| FaxNumber: | 7042632591 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STANLEY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042638945 | ||||||||
| FaxNumber: | 7042632591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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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 | 207Q00000X | 2006-01670 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1871678110 | 05 | NC | MEDICAID |