Provider Demographics
NPI:1699324665
Name:KIETZMANN, BRENNA MARIE
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:MARIE
Last Name:KIETZMANN
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 1:20650 PARALLEL RD
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-5348
Mailing Address - Country:US
Mailing Address - Phone:913-626-1886
Mailing Address - Fax:
Practice Address - Street 1:1198 FRONT ST
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-9707
Practice Address - Country:US
Practice Address - Phone:913-417-7400
Practice Address - Fax:913-369-2836
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03370225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant