Provider Demographics
NPI:1316987316
Name:BRENNER, MICHELLE THERESA (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THERESA
Last Name:BRENNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 HARLEM RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14206-1964
Mailing Address - Country:US
Mailing Address - Phone:716-893-1010
Mailing Address - Fax:716-893-1002
Practice Address - Street 1:40 LA RIVIERE DR STE 201
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-4344
Practice Address - Country:US
Practice Address - Phone:716-893-1010
Practice Address - Fax:716-893-1002
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3336961363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
9512100OtherIHA
NYRB4777Medicare PIN
NYDD6257Medicare PIN
9512100OtherIHA
P93412Medicare UPIN