Provider Demographics
NPI:1811922024
Name:BRENEK, JUDY A (RN/CNP)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:BRENEK
Suffix:
Gender:F
Credentials:RN/CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1005 BELLEFONTAINE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2851
Practice Address - Country:US
Practice Address - Phone:419-227-5298
Practice Address - Fax:419-227-5879
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN162141363L00000X
OHAPRN.CNP.04615363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2134158Medicaid
OHH070530Medicare PIN
OH2134158Medicaid