Healthcare Provider Details

I. General information

NPI: 1174995310
Provider Name (Legal Business Name): LAURA LYNN BRENNECKE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4399
US

IV. Provider business mailing address

409 SECOND AVE SUITE 303
COLLEGEVILLE PA
19426-3625
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-3630
  • Fax:
Mailing address:
  • Phone: 610-409-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP015549
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: