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General NPI Number Information
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NPI Number | 1073583480
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Entity Type | Individual
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Provider Name | BRENDA J LIFE CNP
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Gender | Female
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Dates
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Enumeration Date | 01/26/2006
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Last Update Date | 04/07/2011
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Provider Practice Location Address
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Address Line | 125 E BROAD ST SUITE 305
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City | ELYRIA
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State | OH
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Zip | 44035-6400
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Country | US
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Telephone | 440-326-4120
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Fax | 440-322-3454
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Provider Business Mailing Address
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Address Line | 1220 MOORE RD SUITE B
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City | AVON
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State | OH
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Zip | 44011-4044
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Country | US
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Telephone | 440-930-4446
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Fax | 440-934-0682
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | NP-00697
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License Number State | OH
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