Healthcare Provider Details

I. General information

NPI: 1891014577
Provider Name (Legal Business Name): MS. BRENETTA MARIE GEDDIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 AYERS ST
YOUNGSTOWN OH
44506-1529
US

IV. Provider business mailing address

247 AYERS ST
YOUNGSTOWN OH
44506-1529
US

V. Phone/Fax

Practice location:
  • Phone: 330-519-4074
  • Fax:
Mailing address:
  • Phone: 330-519-4074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: