MEDICARE: MRS. BRENDA LEE ELLIOTT RN

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	163WS0200X	School Registered Nurse	361343	OH

General Provider Information

NPI Number	:	1659795185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRENDA LEE ELLIOTT RN

Provider Business Mailing Address
First Line	:	4154 NORTHMOOR RD
Second Line	:
City	:	OTTAWA HILLS
State	:	OH
Zip	:	43606-2231
Country	:	US
Telephone Number	:	419-320-0370
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 FOREST AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43607-1947
Country	:	US
Telephone Number	:	419-671-4550
Fax Number	:	419-671-4595

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

Provider Enumeration Date	:	02/04/2014
Last Update Date	:	02/04/2014

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