Provider Demographics
NPI:1043640337
Name:WODARSKI, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:WODARSKI
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 1:3761 BRADWOOD CT NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-2722
Mailing Address - Country:US
Mailing Address - Phone:616-540-3038
Mailing Address - Fax:
Practice Address - Street 1:3109 S BLUFF CT
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1580
Practice Address - Country:US
Practice Address - Phone:616-209-5029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS700317377376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator