Healthcare Provider Details

I. General information

NPI: 1225906050
Provider Name (Legal Business Name): AVERY BRENNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 STANWOOD ST STE 1
BRUNSWICK ME
04011-2811
US

IV. Provider business mailing address

163 FORE ST FL 2
PORTLAND ME
04101-6806
US

V. Phone/Fax

Practice location:
  • Phone: 207-508-1062
  • Fax:
Mailing address:
  • Phone: 207-495-8148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF10250684
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: