Healthcare Provider Details

I. General information

NPI: 1770050049
Provider Name (Legal Business Name): NICOLETTO BOLZAN-ROCHE APRN, NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 KOLBE RD STE 106
LORAIN OH
44053-1652
US

IV. Provider business mailing address

3600 KOLBE RD STE 106
LORAIN OH
44053-1652
US

V. Phone/Fax

Practice location:
  • Phone: 440-960-3954
  • Fax: 440-960-3956
Mailing address:
  • Phone: 440-960-3954
  • Fax: 440-960-3956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.361488
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.023837
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: