Healthcare Provider Details

I. General information

NPI: 1023641651
Provider Name (Legal Business Name): PAULA K HURT HERITAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5118 STATE ROUTE 303
RAVENNA OH
44266-9721
US

IV. Provider business mailing address

5118 STATE ROUTE 303
RAVENNA OH
44266-9721
US

V. Phone/Fax

Practice location:
  • Phone: 330-931-8993
  • Fax:
Mailing address:
  • Phone: 330-931-8993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number161965
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: