Healthcare Provider Details

I. General information

NPI: 1760788053
Provider Name (Legal Business Name): LORI ANN MARIETTA ACNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 WHIPPLE AVE NW
NORTH CANTON OH
44720-7618
US

IV. Provider business mailing address

6100 WHIPPLE AVE NW
NORTH CANTON OH
44720-7618
US

V. Phone/Fax

Practice location:
  • Phone: 330-244-8118
  • Fax: 330-244-8329
Mailing address:
  • Phone: 330-244-8118
  • Fax: 330-244-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number259463
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number11388-NS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: