Provider Demographics
NPI:1619751880
Name:DOUGLAS, BRENDA SUE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:SUE
Last Name:DOUGLAS
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 1:121 HOCKEY RD
Mailing Address - Street 2:
Mailing Address - City:TARRS
Mailing Address - State:PA
Mailing Address - Zip Code:15688-2102
Mailing Address - Country:US
Mailing Address - Phone:407-697-2436
Mailing Address - Fax:
Practice Address - Street 1:2380 MCGINLEY RD
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-4400
Practice Address - Country:US
Practice Address - Phone:407-697-2436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN731204163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse