Healthcare Provider Details

I. General information

NPI: 1093118374
Provider Name (Legal Business Name): JULIE ANN PRUSOCK AT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9309 DEWEY RD
KIRTLAND OH
44094-5173
US

IV. Provider business mailing address

9309 DEWEY RD
KIRTLAND OH
44094-5173
US

V. Phone/Fax

Practice location:
  • Phone: 216-402-3495
  • Fax:
Mailing address:
  • Phone: 440-729-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-001330
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: