Healthcare Provider Details

I. General information

NPI: 1720470909
Provider Name (Legal Business Name): MRS. TATYANA MARICIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MARTIN LUTHER KING JR DR
CLEVELAND OH
44104-3815
US

IV. Provider business mailing address

6054 PEARL RD
PARMA HEIGHTS OH
44130-2002
US

V. Phone/Fax

Practice location:
  • Phone: 216-448-6400
  • Fax:
Mailing address:
  • Phone: 440-212-6227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number394987
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number394987
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: