Provider Demographics
NPI:1043484371
Name:BRENEMAN, MICHELLE LYNN (PNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:BRENEMAN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:PO BOX 505405
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5405
Mailing Address - Country:US
Mailing Address - Phone:636-561-5437
Mailing Address - Fax:636-561-5100
Practice Address - Street 1:100 BREVCO PLZ
Practice Address - Street 2:STE 101
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1382
Practice Address - Country:US
Practice Address - Phone:636-561-5437
Practice Address - Fax:636-561-5100
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003020311363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420041212Medicaid