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General NPI Number Information
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NPI Number | 1396162079
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Entity Type | Individual
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Provider Name | BRENDA LEE LESTOCK AT/L
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Gender | Female
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Dates
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Enumeration Date | 03/19/2014
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Last Update Date | 03/04/2018
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Provider Practice Location Address
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Address Line | 1755 RUSTIC TIMBERS LN APT 205
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City | PRESCOTT
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State | AZ
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Zip | 86303-6902
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Country | US
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Telephone | 330-903-1018
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Fax |
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Provider Business Mailing Address
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Address Line | 50 HILLSIDE CT
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City | HOWARD
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State | OH
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Zip | 43028-8052
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Country | US
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Telephone | 330-903-1018
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Fax |
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 1033
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 1361
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License Number State | OH
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