Healthcare Provider Details

I. General information

NPI: 1568703866
Provider Name (Legal Business Name): BRENNA L HUTZLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 SALISBURY RD
JACKSONVILLE FL
32216-6123
US

IV. Provider business mailing address

4311 SALISBURY RD
JACKSONVILLE FL
32216-6123
US

V. Phone/Fax

Practice location:
  • Phone: 904-332-4316
  • Fax: 904-332-4339
Mailing address:
  • Phone: 904-332-4316
  • Fax: 904-332-4339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9107088
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: