Healthcare Provider Details

I. General information

NPI: 1902099062
Provider Name (Legal Business Name): BRENDA DELORES TODD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

IV. Provider business mailing address

3753 WILCOX RD
POPLAR BLUFF MO
63901-2250
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-4151
  • Fax:
Mailing address:
  • Phone: 157-377-8028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number2005000247
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: