1780637041 NPI number — BRENDA NICHOLS-OMIECINSKI CRNA

Table of content: BRENDA NICHOLS-OMIECINSKI CRNA (NPI 1780637041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780637041 NPI number — BRENDA NICHOLS-OMIECINSKI CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS-OMIECINSKI
Provider First Name:
BRENDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NICHOLS
Provider Other First Name:
BRENDA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780637041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 526
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVELTY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44072-0526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-285-6000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13207 RAVENNA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARDON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44024-7032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-285-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN166962 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: RN166962 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000516002 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 750937 . This is a "BUCKEYE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00403006 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 7516119 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000221285 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0583328 . This is a "BCMH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2389339 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 415014 . This is a "WELLCARE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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