MEDICARE: KAHLA GAGNE

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	363LP2300X	Primary Care Nurse Practitioner	RN.368003-COA17217	OH

General Provider Information

NPI Number	:	1205221264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAHLA GAGNE

Provider Business Mailing Address
First Line	:	11100 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-1716
Country	:	US
Telephone Number	:	216-286-5595
Fax Number	:

Provider Business Practice Location Address
First Line	:	1305 STONEY RUN TRL
Second Line	:
City	:	BROADVIEW HEIGHTS
State	:	OH
Zip	:	44147-2555
Country	:	US
Telephone Number	:	440-315-4511
Fax Number	:

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

Provider Enumeration Date	:	04/06/2015
Last Update Date	:	04/06/2015

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