Healthcare Provider Details

I. General information

NPI: 1265487391
Provider Name (Legal Business Name): ANGELA GELLINGS MARDULA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6780 MAYFIELD RD
MAYFIELD HEIGHTS OH
44124
US

IV. Provider business mailing address

11800 JULIE DR
CHARDON OH
44024-8484
US

V. Phone/Fax

Practice location:
  • Phone: 440-312-4600
  • Fax:
Mailing address:
  • Phone: 440-214-9546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: