Healthcare Provider Details

I. General information

NPI: 1558027565
Provider Name (Legal Business Name): NICOLE ELIZABETH SANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2021
Last Update Date: 11/14/2021
Certification Date: 11/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TUSCARAWAS ST W STE 200
CANTON OH
44702-2044
US

IV. Provider business mailing address

5982 RHODES RD
KENT OH
44240-8100
US

V. Phone/Fax

Practice location:
  • Phone: 330-438-2400
  • Fax:
Mailing address:
  • Phone: 330-673-1347
  • Fax: 330-678-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: