Healthcare Provider Details

I. General information

NPI: 1750341798
Provider Name (Legal Business Name): SANDRA JEAN WAHL-PIECUCH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 MENTOR AVE STE 215
MENTOR OH
44060-4498
US

IV. Provider business mailing address

24701 EUCLID AVE THIRD FLOOR - BILLING SERVICES
EUCLID OH
44117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 440-205-5870
  • Fax: 440-205-5881
Mailing address:
  • Phone: 440-205-5870
  • Fax: 440-205-5881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN228416 NP08215
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number08215-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: