Basic Information
| Provider Information | |||||||||
| NPI: | 1225076631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKINSTRY | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | JOYCE | ||||||||
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| Credential: | MSN CPMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 CLEVELAND AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447021805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304550374 | ||||||||
| FaxNumber: | 3304536716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1680 NAVE RD SE | ||||||||
| Address2: | |||||||||
| City: | MASSILLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308308410 | ||||||||
| FaxNumber: | 3308300912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | APRN.CNP.08313 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363L00000X | NP08313 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2580256 | 05 | OH | MEDICAID |