Provider Demographics
NPI:1992860332
Name:STACKER, BRENDA LEE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LEE
Last Name:STACKER
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 1:401 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-1640
Mailing Address - Country:US
Mailing Address - Phone:419-238-6772
Mailing Address - Fax:
Practice Address - Street 1:401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-1640
Practice Address - Country:US
Practice Address - Phone:419-238-6772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN090365164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse