Healthcare Provider Details

I. General information

NPI: 1871587808
Provider Name (Legal Business Name): KELLY R CERVENKA CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4229 PEARL RD
CLEVELAND OH
44109-4218
US

IV. Provider business mailing address

10275 CLIPPER CV
REMINDERVILLE OH
44202-9042
US

V. Phone/Fax

Practice location:
  • Phone: 216-205-4026
  • Fax: 216-205-4032
Mailing address:
  • Phone: 330-562-2630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA.04944-NP
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN211663
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: