Provider Demographics
NPI:1780637041
Name:NICHOLS, BRENDA (CRNA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 526
Mailing Address - Street 2:
Mailing Address - City:NOVELTY
Mailing Address - State:OH
Mailing Address - Zip Code:44072-0526
Mailing Address - Country:US
Mailing Address - Phone:440-285-6000
Mailing Address - Fax:
Practice Address - Street 1:13207 RAVENNA RD
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-7032
Practice Address - Country:US
Practice Address - Phone:440-285-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN166962163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000516002OtherANTHEM
OH0583328OtherBCMH
OH7516119OtherAETNA
OH2389339Medicaid
OH000000221285OtherUNISON
OHP00403006OtherMEDICARE RAILROAD
OH415014OtherWELLCARE MEDICAID
OH750937OtherBUCKEYE MEDICAID
OH750937OtherBUCKEYE MEDICAID