Provider Demographics
NPI:1497854467
Name:PALM, BRENDA A (OTR)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:A
Last Name:PALM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10305 DAWSONS CREEK BLVD
Mailing Address - Street 2:STE F
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1914
Mailing Address - Country:US
Mailing Address - Phone:260-497-0328
Mailing Address - Fax:260-497-0904
Practice Address - Street 1:10305 DAWSONS CREEK BLVD
Practice Address - Street 2:STE F
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1914
Practice Address - Country:US
Practice Address - Phone:260-497-0328
Practice Address - Fax:260-497-0904
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003508A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist