Provider Demographics
NPI:1104035799
Name:WALTON, BRENDA (LPN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17705 WINSLOW RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4857
Mailing Address - Country:US
Mailing Address - Phone:216-752-0054
Mailing Address - Fax:216-752-0054
Practice Address - Street 1:381 ROYAL OAK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-1709
Practice Address - Country:US
Practice Address - Phone:216-486-6193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN. 066863164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2278093Medicare UPIN