Healthcare Provider Details

I. General information

NPI: 1346786407
Provider Name (Legal Business Name): DIANE HERRILKO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1744 PAYNE AVE
CLEVELAND OH
44114-2910
US

IV. Provider business mailing address

1744 PAYNE AVE
CLEVELAND OH
44114-2910
US

V. Phone/Fax

Practice location:
  • Phone: 216-551-7565
  • Fax: 216-623-6539
Mailing address:
  • Phone: 216-551-7565
  • Fax: 216-623-6539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number320358
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: