Provider Demographics
NPI:1679231690
Name:BRENNAN, AUDREY MICHELLE (FNP-C)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:MICHELLE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:MICHELLE
Other - Last Name:DARBONNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:4 MEMORIAL DR STE 230
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6704
Practice Address - Country:US
Practice Address - Phone:618-465-8666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021048680363L00000X, 363LF0000X
IL209025875363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily