Provider Demographics
NPI:1770893380
Name:PESTAK, BRENDA GERILYN (RN ICCE DOULA)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:GERILYN
Last Name:PESTAK
Suffix:
Gender:F
Credentials:RN ICCE DOULA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3478 HANOVER DR.
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212
Mailing Address - Country:US
Mailing Address - Phone:216-319-0409
Mailing Address - Fax:
Practice Address - Street 1:6780 MAYFIELD RD.
Practice Address - Street 2:
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124
Practice Address - Country:US
Practice Address - Phone:440-312-4647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-197127374J00000X
OHRN197127374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula