Healthcare Provider Details

I. General information

NPI: 1164056305
Provider Name (Legal Business Name): BRENNA FOX PMHNP-BC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 LINWOOD AVE
WILLIAMSVILLE NY
14221-6501
US

IV. Provider business mailing address

15 BRIARWOOD LN
GRAND ISLAND NY
14072-1972
US

V. Phone/Fax

Practice location:
  • Phone: 716-626-9016
  • Fax:
Mailing address:
  • Phone: 716-626-9016
  • Fax: 716-626-4271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRENNA E FOX
Title or Position: OWNER
Credential:
Phone: 716-545-8161