MEDICARE: KRYSTAL BRANTLEY

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	171M00000X	Case Manager/Care Coordinator		OH
2	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1578093332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL BRANTLEY

Provider Business Mailing Address
First Line	:	2526 E 33RD ST
Second Line	:
City	:	LORAIN
State	:	OH
Zip	:	44055-2135
Country	:	US
Telephone Number	:	216-242-8152
Fax Number	:

Provider Business Practice Location Address
First Line	:	5238 ERWIN ST
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-1528
Country	:	US
Telephone Number	:	216-505-3178
Fax Number	:

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

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	10/18/2021

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Directions to “ KRYSTAL BRANTLEY ” Practice Location

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