Provider Demographics
NPI:1992244594
Name:STEWART, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14317 E 2000S RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE TOWNSHIP
Mailing Address - State:IL
Mailing Address - Zip Code:60958-3674
Mailing Address - Country:US
Mailing Address - Phone:815-272-1326
Mailing Address - Fax:
Practice Address - Street 1:14317 E 2000S RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE TOWNSHIP
Practice Address - State:IL
Practice Address - Zip Code:60958-3674
Practice Address - Country:US
Practice Address - Phone:815-272-1326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041303647163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse