Provider Demographics
NPI:1053569459
Name:BRANDENBURG, BETH ANN (LPN)
Entity type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 DIRLAM LN
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1797
Mailing Address - Country:US
Mailing Address - Phone:419-756-6413
Mailing Address - Fax:
Practice Address - Street 1:542 DIRLAM LN
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44904-1797
Practice Address - Country:US
Practice Address - Phone:419-756-6413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.091346164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse