Healthcare Provider Details

I. General information

NPI: 1114164324
Provider Name (Legal Business Name): PENNY RENE O'BRIEN-BLACK CNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19999 ROCKSIDE RD
BEDFORD OH
44146-2074
US

IV. Provider business mailing address

19999 ROCKSIDE RD
BEDFORD OH
44146-2074
US

V. Phone/Fax

Practice location:
  • Phone: 216-524-7377
  • Fax:
Mailing address:
  • Phone: 216-524-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP-10452
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: