Provider Demographics
NPI:1235698093
Name:FANNING, BRENNA (MD)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:FANNING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 S CRYSTAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1506
Mailing Address - Country:US
Mailing Address - Phone:406-496-3480
Mailing Address - Fax:
Practice Address - Street 1:435 S CRYSTAL ST STE 200
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1506
Practice Address - Country:US
Practice Address - Phone:406-496-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MTMED-PHYS-LIC-143760208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program