Healthcare Provider Details

I. General information

NPI: 1588434088
Provider Name (Legal Business Name): BRANDEN CRUM STNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 GEORGETOWN AVE APT F11
ELYRIA OH
44035-3823
US

IV. Provider business mailing address

525 GEORGETOWN AVE APT F11
ELYRIA OH
44035-3823
US

V. Phone/Fax

Practice location:
  • Phone: 440-308-9369
  • Fax:
Mailing address:
  • Phone: 440-308-9369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number602772761223
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: