Healthcare Provider Details

I. General information

NPI: 1134579378
Provider Name (Legal Business Name): NICOLE TIJERINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2016
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W BOGART RD
SANDUSKY OH
44870-7119
US

IV. Provider business mailing address

315 W BOGART RD
SANDUSKY OH
44870-7119
US

V. Phone/Fax

Practice location:
  • Phone: 216-903-7928
  • Fax:
Mailing address:
  • Phone: 216-903-7928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberTV413777
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2513160
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: