Healthcare Provider Details

I. General information

NPI: 1659796142
Provider Name (Legal Business Name): JULIANNE GROSSNICKLE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 MERCY DR NW
CANTON OH
44708-2614
US

IV. Provider business mailing address

822 KUMHO DR SUITE 202
FAIRLAWN OH
44333-9297
US

V. Phone/Fax

Practice location:
  • Phone: 330-489-1000
  • Fax:
Mailing address:
  • Phone: 330-576-0500
  • Fax: 330-576-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCOA-15658-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: