Healthcare Provider Details

I. General information

NPI: 1992351290
Provider Name (Legal Business Name): BRENTON A HALLDEN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 4TH ST
LEWISPORT KY
42351-2529
US

IV. Provider business mailing address

PO BOX 1099
OWENSBORO KY
42302-1099
US

V. Phone/Fax

Practice location:
  • Phone: 270-295-3890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3013698
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71011067A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3013698
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: