Healthcare Provider Details

I. General information

NPI: 1063592632
Provider Name (Legal Business Name): ANGELIQUE SCOTT AA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

3605 WARRENSVILLE CENTER RD 1ST FLOOR
SHAKER HTS OH
44122-5203
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-7337
  • Fax:
Mailing address:
  • Phone: 216-286-6260
  • Fax: 216-286-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1410
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number67.000125
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: