Healthcare Provider Details

I. General information

NPI: 1386223717
Provider Name (Legal Business Name): EMMA S CHAMPLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2021
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1794 W 48TH ST
CLEVELAND OH
44102-3416
US

IV. Provider business mailing address

1794 W 48TH ST
CLEVELAND OH
44102-3416
US

V. Phone/Fax

Practice location:
  • Phone: 561-346-0014
  • Fax:
Mailing address:
  • Phone: 561-346-0014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1187107
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: