Provider Demographics
NPI:1447815188
Name:BRENNAN, AMANDA JO (BS/P)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:BS/P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 GEORGIA AVE APT 43
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062-5560
Mailing Address - Country:US
Mailing Address - Phone:317-697-4955
Mailing Address - Fax:
Practice Address - Street 1:2624 GEORGIA AVE APT 43
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-5560
Practice Address - Country:US
Practice Address - Phone:317-697-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator