Healthcare Provider Details

I. General information

NPI: 1396101960
Provider Name (Legal Business Name): HEATHER KUPETZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13883 DRAKE RD
STRONGSVILLE OH
44136-7918
US

IV. Provider business mailing address

19982 ENNIS DR
STRONGSVILLE OH
44149-0990
US

V. Phone/Fax

Practice location:
  • Phone: 440-268-5677
  • Fax:
Mailing address:
  • Phone: 440-539-0490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number283545
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: