Healthcare Provider Details

I. General information

NPI: 1073583480
Provider Name (Legal Business Name): BRENDA J LIFE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E BROAD ST SUITE 305
ELYRIA OH
44035-6400
US

IV. Provider business mailing address

1220 MOORE RD SUITE B
AVON OH
44011-4044
US

V. Phone/Fax

Practice location:
  • Phone: 440-326-4120
  • Fax: 440-322-3454
Mailing address:
  • Phone: 440-930-4446
  • Fax: 440-934-0682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP-00697
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: