Basic Information
| Provider Information | |||||||||
| NPI: | 1912311838 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | BRENTON | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 W BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378014703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 BMH PHYSICIANS OFFICE BLDG | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659805244 | ||||||||
| FaxNumber: | 8659805245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2014 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN165538 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | APN18684 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.