Basic Information
| Provider Information | |||||||||
| NPI: | 1245251057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIDDER | ||||||||
| FirstName: | BRENDA | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447700 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0200X | 1802-NS | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 750700 | 01 | OH | BUCKEYE | OTHER | 000000224407 | 01 | OH | UNISON | OTHER | 000000370806 | 01 | OH | ANTHEM | OTHER | 2776830 | 05 | OH | MEDICAID | 363699 | 01 | OH | WELLCARE | OTHER | 1021104990001 | 01 | PA | PA MEDICAID | OTHER | 7876700 | 01 | OH | AETNA | OTHER | 000000526071 | 01 | OH | ANTHEM | OTHER |