Provider Demographics
NPI:1003434952
Name:LISCOE, BRETZYL M
Entity Type:Individual
Prefix:
First Name:BRETZYL
Middle Name:M
Last Name:LISCOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17703 HICKS RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-4332
Mailing Address - Country:US
Mailing Address - Phone:440-525-0811
Mailing Address - Fax:
Practice Address - Street 1:630 E RIVER ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5902
Practice Address - Country:US
Practice Address - Phone:440-323-8515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0027013363LA2100X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care