Provider Demographics
NPI:1396454021
Name:MUTEHART, BRENDA (APRN)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MUTEHART
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:MUTEHART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:35 CREEKSIDE CIR APT D
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-1103
Mailing Address - Country:US
Mailing Address - Phone:224-628-4456
Mailing Address - Fax:
Practice Address - Street 1:35 CREEKSIDE CIR APT D
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1103
Practice Address - Country:US
Practice Address - Phone:224-628-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00000000000000000000363LF0000X
IL209026643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily