Healthcare Provider Details

I. General information

NPI: 1073589180
Provider Name (Legal Business Name): KIMBERLY A RERICHA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: KIMBERLY A MICKNOWSKI

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18901 LAKE SHORE BLVD
EUCLID OH
44119-1078
US

IV. Provider business mailing address

PO BOX 74253
CLEVELAND OH
44194-0002
US

V. Phone/Fax

Practice location:
  • Phone: 216-531-9000
  • Fax:
Mailing address:
  • Phone: 440-879-0081
  • Fax: 440-879-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50-002407
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: