Healthcare Provider Details

I. General information

NPI: 1205651940
Provider Name (Legal Business Name): REQUETTA MERRITT BSN,RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PORTAGE PATH BEHAVIORAL HEALTH 10 PENFIELD AVE
AKRON OH
44310
US

IV. Provider business mailing address

3496 WYOGA LAKE RD APT 101
CUYAHOGA FALLS OH
44224-6825
US

V. Phone/Fax

Practice location:
  • Phone: 330-762-6110
  • Fax:
Mailing address:
  • Phone: 330-344-0205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number500176
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: