Healthcare Provider Details

I. General information

NPI: 1093022246
Provider Name (Legal Business Name): ELIZABETH ANN BRENNAN NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1456 FAWNVALLEY CT
DES PERES MO
63131-4219
US

V. Phone/Fax

Practice location:
  • Phone: 314-504-3453
  • Fax:
Mailing address:
  • Phone: 314-504-3453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number2010031567
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: