MEDICARE: BRENDA K CLEMENS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	71001942A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IT764Z	OTHER	FL	MEDICARE

General Provider Information

NPI Number	:	1740232230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA K CLEMENS NP

Provider Business Mailing Address
First Line	:	1326 MALABAR RD SE STE 3
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2502
Country	:	US
Telephone Number	:	321-409-6100
Fax Number	:	321-409-6063

Provider Business Practice Location Address
First Line	:	1326 MALABAR RD SE STE 3
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2502
Country	:	US
Telephone Number	:	321-409-6100
Fax Number	:	321-409-6063

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	11/04/2017

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