Healthcare Provider Details

I. General information

NPI: 1548234958
Provider Name (Legal Business Name): GWENN HOLLER CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 LORAIN AVENUE
CLEVELAND OH
44111
US

IV. Provider business mailing address

PO BOX 74953
CLEVELAND OH
44194-1036
US

V. Phone/Fax

Practice location:
  • Phone: 216-476-7000
  • Fax:
Mailing address:
  • Phone: 440-879-0081
  • Fax: 440-879-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberNS-04321
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: