Healthcare Provider Details

I. General information

NPI: 1679913701
Provider Name (Legal Business Name): BRANDIE CHILDRESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 S GREEN RD
SOUTH EUCLID OH
44121-4243
US

IV. Provider business mailing address

2054 S GREEN RD
SOUTH EUCLID OH
44121-4243
US

V. Phone/Fax

Practice location:
  • Phone: 216-291-9210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number14636
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: