Healthcare Provider Details

I. General information

NPI: 1346683182
Provider Name (Legal Business Name): BRENNA B BOHATEC FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MEDICAL PARK BLVD SUITE 200
PETERSBURG VA
23805-9338
US

IV. Provider business mailing address

7202 GLEN FOREST DR SUITE 200
RICHMOND VA
23226-3781
US

V. Phone/Fax

Practice location:
  • Phone: 804-431-1100
  • Fax: 804-862-1094
Mailing address:
  • Phone: 804-676-2024
  • Fax: 804-673-1796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024170794
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: