Healthcare Provider Details

I. General information

NPI: 1518356864
Provider Name (Legal Business Name): IRENE CHRYSSOVALANTOU GRABOVAC NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IRENE NIKOKIRAKIS

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 HALE ST
AVON OH
44011-1856
US

IV. Provider business mailing address

26908 DETROIT RD SUITE 301
WESTLAKE OH
44145-2398
US

V. Phone/Fax

Practice location:
  • Phone: 440-934-8810
  • Fax: 440-934-8811
Mailing address:
  • Phone: 440-892-6406
  • Fax: 440-617-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15784-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: