Provider Demographics
NPI:1750793485
Name:WILSON, BRENDA JOYCE (STNA)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:JOYCE
Last Name:WILSON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 E 156TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-3069
Mailing Address - Country:US
Mailing Address - Phone:216-851-0415
Mailing Address - Fax:216-851-0415
Practice Address - Street 1:791 E 156TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-3069
Practice Address - Country:US
Practice Address - Phone:216-851-0415
Practice Address - Fax:216-851-0415
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401618880314374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide