Healthcare Provider Details

I. General information

NPI: 1780637041
Provider Name (Legal Business Name): BRENDA NICHOLS-OMIECINSKI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA NICHOLS

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13207 RAVENNA RD
CHARDON OH
44024-7032
US

IV. Provider business mailing address

PO BOX 526
NOVELTY OH
44072-0526
US

V. Phone/Fax

Practice location:
  • Phone: 440-285-6000
  • Fax:
Mailing address:
  • Phone: 440-285-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN166962
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN166962
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: