Provider Demographics
NPI:1699782623
Name:BRENNAN, MARY J (APRN-BC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1954
Mailing Address - Country:US
Mailing Address - Phone:207-761-6642
Mailing Address - Fax:
Practice Address - Street 1:10 ANDOVER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1954
Practice Address - Country:US
Practice Address - Phone:207-761-6642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP211468363LA2100X
NH047934-23363LA2100X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432951999Medicaid
NH30347119Medicaid
NH30347119Medicaid
ME432951999Medicaid
NH000745301Medicare PIN
NHP00668258Medicare PIN