Healthcare Provider Details

I. General information

NPI: 1972719060
Provider Name (Legal Business Name): MRS. MICHELE L HUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 E MOHAWK DR
MALVERN OH
44644-9505
US

IV. Provider business mailing address

542 E MOHAWK DR
MALVERN OH
44644-9505
US

V. Phone/Fax

Practice location:
  • Phone: 330-863-0524
  • Fax:
Mailing address:
  • Phone: 330-863-0524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN047793
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: