Healthcare Provider Details

I. General information

NPI: 1508706771
Provider Name (Legal Business Name): LILY HERTEL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13207 RAVENNA RD
CHARDON OH
44024-7032
US

IV. Provider business mailing address

3827 BROOKS RD
GASPORT NY
14067-9307
US

V. Phone/Fax

Practice location:
  • Phone: 440-285-6000
  • Fax:
Mailing address:
  • Phone: 585-640-1556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: