Healthcare Provider Details

I. General information

NPI: 1366400350
Provider Name (Legal Business Name): BRENDA LEILANI OWEN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LRMC ATTN: MCEUL-OB/GYN CMR 402
APO AE
09180
DE

IV. Provider business mailing address

LRMC ATTN: MCEUL-DCCS (CREDENTIALS), CMR 402
APO AE
09180
DE

V. Phone/Fax

Practice location:
  • Phone: 011496371868124
  • Fax: 011496371868557
Mailing address:
  • Phone: 011496371868839
  • Fax: 011496371866133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number217042-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: