Healthcare Provider Details

I. General information

NPI: 1437698495
Provider Name (Legal Business Name): BRENDA SUE WELTLICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 MCKINLEY AVE NW
CANTON OH
44703-2463
US

IV. Provider business mailing address

832 MCKINLEY AVE NW
CANTON OH
44703-2463
US

V. Phone/Fax

Practice location:
  • Phone: 330-455-9407
  • Fax:
Mailing address:
  • Phone: 330-455-9407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number291535
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: