Healthcare Provider Details

I. General information

NPI: 1386203768
Provider Name (Legal Business Name): DEIRDRE ICE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13422 KINSMAN RD
CLEVELAND OH
44120-4410
US

IV. Provider business mailing address

16225 CYNTHIA DR
BROOKPARK OH
44142-2713
US

V. Phone/Fax

Practice location:
  • Phone: 216-283-4400
  • Fax: 216-283-5359
Mailing address:
  • Phone: 216-283-4400
  • Fax: 216-283-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN.454681
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: