MEDICARE: TARA RANITA EDWARDS-COLEMAN RN

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	164W00000X	Licensed Practical Nurse	PN-133601	OH
2	163W00000X	Registered Nurse	445261	OH

General Provider Information

NPI Number	:	1063644086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA RANITA EDWARDS-COLEMAN RN

Provider Business Mailing Address
First Line	:	732 QUILLIAMS RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1956
Country	:	US
Telephone Number	:	216-785-4486
Fax Number	:

Provider Business Practice Location Address
First Line	:	17325 EUCLID AVE STE 3022
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-1255
Country	:	US
Telephone Number	:	216-260-3444
Fax Number	:

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

Provider Enumeration Date	:	08/10/2009
Last Update Date	:	11/25/2020

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