Provider Demographics
NPI:1275703647
Name:WALLACE, BRENDA JANICE (RN,C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JANICE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 EASTWICK DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1222
Mailing Address - Country:US
Mailing Address - Phone:216-371-5253
Mailing Address - Fax:
Practice Address - Street 1:3107 EASTWICK DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1222
Practice Address - Country:US
Practice Address - Phone:216-371-5253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN225158163W00000X
OH163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WG0600XNursing Service ProvidersRegistered NurseGerontology