MEDICARE: DARESHA JOY GRACE 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	163WC0400X	Case Management Registered Nurse	RN-310004	OH

General Provider Information

NPI Number	:	1720791502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARESHA JOY GRACE RN

Provider Business Mailing Address
First Line	:	18207 MAPLEBORO AVE
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-2722
Country	:	US
Telephone Number	:	216-392-9795
Fax Number	:

Provider Business Practice Location Address
First Line	:	10701 EAST BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-1782
Country	:	US
Telephone Number	:	216-791-3800
Fax Number	:

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

Provider Enumeration Date	:	12/27/2022
Last Update Date	:	12/27/2022

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