Healthcare Provider Details

I. General information

NPI: 1295828879
Provider Name (Legal Business Name): KEVIN FRANCIS BRENNAN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KEVIN F BRENNAN FNP-C

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 STONE ST
WATERTOWN NY
13601
US

IV. Provider business mailing address

RED LAKE HOSPITAL PO BOX 497, HIGHWAY 1
RED LAKE MN
56671
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7400
  • Fax: 315-782-7460
Mailing address:
  • Phone: 218-679-3912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number32 320050
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: