Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | R047461 | ME |
NPI | 1063517654 |
---|---|
Provider Name | Stacy Brenner |
First Address | Portland, ME 04103-4972 |
Second Address | Portland, ME 04103-4972 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2006 |
Last Update Date | 08/07/2007 |