Provider Demographics
NPI:1487709366
Name:STAUFFER, BRENDA J (CNP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:STAUFFER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:J
Other - Last Name:PETRENCSIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 74216
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0002
Mailing Address - Country:US
Mailing Address - Phone:440-879-0081
Mailing Address - Fax:440-879-0084
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-3108
Practice Address - Country:US
Practice Address - Phone:216-445-6532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-06737363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2519402Medicaid
OH000000325969OtherANTHEM
OHP71254Medicare UPIN
OHPENP11572Medicare ID - Type Unspecified