Provider Demographics
NPI:1740689835
Name:STALLWORTH, BRANDIE MIYA
Entity type:Individual
Prefix:
First Name:BRANDIE
Middle Name:MIYA
Last Name:STALLWORTH
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 1:101 WINKLER ST
Mailing Address - Street 2:101 WINKLER
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-1867
Mailing Address - Country:US
Mailing Address - Phone:513-203-4776
Mailing Address - Fax:
Practice Address - Street 1:101 WINKLER ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-1867
Practice Address - Country:US
Practice Address - Phone:513-203-4776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRT238430376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide