Provider Demographics
NPI:1578395216
Name:BRENES, NICOLE MICHELLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:BRENES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11327 ROSSIE MOOR LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-1750
Mailing Address - Country:US
Mailing Address - Phone:510-909-3521
Mailing Address - Fax:
Practice Address - Street 1:11327 ROSSIE MOOR LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-1750
Practice Address - Country:US
Practice Address - Phone:510-909-3521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1075837363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care