Provider Demographics
NPI:1104544006
Name:KILLEN, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:KILLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11016 BRIAROAKS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-5580
Mailing Address - Country:US
Mailing Address - Phone:682-715-1145
Mailing Address - Fax:
Practice Address - Street 1:11016 BRIAROAKS DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-5580
Practice Address - Country:US
Practice Address - Phone:682-715-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27237520172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver