Provider Demographics
NPI:1396162079
Name:LESTOCK, BRENDA LEE (AT/L)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LEE
Last Name:LESTOCK
Suffix:
Gender:F
Credentials:AT/L
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:LEE
Other - Last Name:LESTOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATHLETIC TRAINER
Mailing Address - Street 1:50 HILLSIDE CT
Mailing Address - Street 2:
Mailing Address - City:HOWARD
Mailing Address - State:OH
Mailing Address - Zip Code:43028-8052
Mailing Address - Country:US
Mailing Address - Phone:330-903-1018
Mailing Address - Fax:
Practice Address - Street 1:1755 RUSTIC TIMBERS LN APT 205
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-6902
Practice Address - Country:US
Practice Address - Phone:330-903-1018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2018-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10332255A2300X
OH1361208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2255A2300XOtherCERTIFIED ATHLETIC TRAINER