MEDICARE: MRS. RUBY LEE FETT FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APRN.CNP.019642	OH
2	163W00000X	Registered Nurse	329386	OH

General Provider Information

NPI Number	:	1003369729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RUBY LEE FETT FNP-C

Provider Business Mailing Address
First Line	:	3233 CHADBOURNE RD
Second Line	:
City	:	SHAKER HEIGHTS
State	:	OH
Zip	:	44120-3378
Country	:	US
Telephone Number	:	216-991-9770
Fax Number	:

Provider Business Practice Location Address
First Line	:	1391 W 5TH AVE
Second Line	:	STE 260
City	:	COLUMBUS
State	:	OH
Zip	:	43212-2902
Country	:	US
Telephone Number	:	615-454-9850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2016
Last Update Date	:	08/08/2016

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