Provider Demographics
NPI:1053739870
Name:HOULIHAN, BRENNA KATE (MD)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:KATE
Last Name:HOULIHAN
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:PO BOX 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:3024 NEW BERN AVE STE 102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1247
Practice Address - Country:US
Practice Address - Phone:919-350-7331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-29
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202102574208600000X
390200000X
NC2021-02574208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053739870Medicaid