Healthcare Provider Details

I. General information

NPI: 1033684212
Provider Name (Legal Business Name): TINA MOUNTS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1553 OAK BRANCH CIR
BRUNSWICK OH
44212-3597
US

IV. Provider business mailing address

1553 OAK BRANCH CIR
BRUNSWICK OH
44212-3597
US

V. Phone/Fax

Practice location:
  • Phone: 216-906-5445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN.433464
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WS0121X
TaxonomyPlastic Surgery Registered Nurse
License NumberRN.433464
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberRN.433464
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN.433464
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: