Healthcare Provider Details

I. General information

NPI: 1457092447
Provider Name (Legal Business Name): MARA JORDEN BRENNER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARA ROETHLE RN

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E BRIDGE ST STE D
WETUMPKA AL
36092-2734
US

IV. Provider business mailing address

49 BIRCHWOOD LN
WETUMPKA AL
36093-1776
US

V. Phone/Fax

Practice location:
  • Phone: 334-782-5565
  • Fax:
Mailing address:
  • Phone: 509-995-5229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberSTUDENT
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61044061
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: