Healthcare Provider Details

I. General information

NPI: 1619178670
Provider Name (Legal Business Name): IETHA L PHILLIPS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1346 SHAWVIEW AVE.
E. CLEVELAND OH
44112-2720
US

IV. Provider business mailing address

1346 SHAWVIEW AVE.
E. CLEVELAND OH
44112
US

V. Phone/Fax

Practice location:
  • Phone: 216-761-1296
  • Fax:
Mailing address:
  • Phone: 216-761-1296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License NumberPN100508
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: