Healthcare Provider Details

I. General information

NPI: 1548971575
Provider Name (Legal Business Name): MICHAELA C HUMPHREY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 12/12/2022
Certification Date: 12/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 ROCKSIDE WOODS BLVD N STE 425
INDEPENDENCE OH
44131-2340
US

IV. Provider business mailing address

6100 ROCKSIDE WOODS BLVD N STE 425
INDEPENDENCE OH
44131-2340
US

V. Phone/Fax

Practice location:
  • Phone: 216-643-2780
  • Fax: 216-524-0111
Mailing address:
  • Phone: 216-643-2780
  • Fax: 216-524-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0032706
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0032706
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: