MEDICARE: BRENDA JANICE WALLACE RN,C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN225158	OH
2	163WG0600X	Gerontology Registered Nurse		OH

General Provider Information

NPI Number	:	1275703647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA JANICE WALLACE RN,C

Provider Business Mailing Address
First Line	:	3107 EASTWICK DR
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1222
Country	:	US
Telephone Number	:	216-371-5253
Fax Number	:

Provider Business Practice Location Address
First Line	:	3107 EASTWICK DR
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1222
Country	:	US
Telephone Number	:	216-371-5253
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	03/03/2008

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