Healthcare Provider Details

I. General information

NPI: 1548876949
Provider Name (Legal Business Name): LI WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2304 LEEWAY DR
HUDSON OH
44236-1819
US

IV. Provider business mailing address

2304 LEEWAY DR
HUDSON OH
44236-1819
US

V. Phone/Fax

Practice location:
  • Phone: 330-671-1225
  • Fax:
Mailing address:
  • Phone: 330-671-1225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0027251
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0027251
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0027251
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0027251
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: