Provider Demographics
NPI:1003779794
Name:BRENNAN, MIRANDA MARY
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MARY
Last Name:BRENNAN
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 1:2009 N 4800 W
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84404-9248
Mailing Address - Country:US
Mailing Address - Phone:385-405-6058
Mailing Address - Fax:
Practice Address - Street 1:4401 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3195
Practice Address - Country:US
Practice Address - Phone:385-405-6058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-08
Last Update Date:2025-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program