Provider Demographics
NPI:1902287188
Name:FOX, BRENDA LEE
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LEE
Last Name:FOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3122 BULL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LAURELVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43135-9605
Mailing Address - Country:US
Mailing Address - Phone:740-655-3039
Mailing Address - Fax:
Practice Address - Street 1:3122 BULL CREEK RD
Practice Address - Street 2:
Practice Address - City:LAURELVILLE
Practice Address - State:OH
Practice Address - Zip Code:43135-9605
Practice Address - Country:US
Practice Address - Phone:740-655-3039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-14
Last Update Date:2015-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2721602374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2721602Medicaid