Healthcare Provider Details

I. General information

NPI: 1780025957
Provider Name (Legal Business Name): ELLEN IMMLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN HAZELET

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 LORAIN AVE
CLEVELAND OH
44111-5612
US

IV. Provider business mailing address

18101 LORAIN AVE
CLEVELAND OH
44111-5612
US

V. Phone/Fax

Practice location:
  • Phone: 216-671-4561
  • Fax:
Mailing address:
  • Phone: 216-671-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03232643
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: