Healthcare Provider Details

I. General information

NPI: 1043047608
Provider Name (Legal Business Name): AMY POTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16004 BROADWAY AVE
MAPLE HEIGHTS OH
44137-2575
US

IV. Provider business mailing address

13314 CRANWOOD DR
GARFIELD HTS OH
44105-6812
US

V. Phone/Fax

Practice location:
  • Phone: 216-269-1487
  • Fax:
Mailing address:
  • Phone: 216-269-1487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: