Healthcare Provider Details

I. General information

NPI: 1235723487
Provider Name (Legal Business Name): MS. NICOLE PAULINE YEFTICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2021
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4757 LORAIN AVE
CLEVELAND OH
44102-3442
US

IV. Provider business mailing address

4757 LORAIN AVE
CLEVELAND OH
44102-3442
US

V. Phone/Fax

Practice location:
  • Phone: 216-957-4848
  • Fax: 216-778-8412
Mailing address:
  • Phone: 216-957-4848
  • Fax: 216-778-8412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2208370
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: