Healthcare Provider Details

I. General information

NPI: 1689286726
Provider Name (Legal Business Name): YASSIN ISMAT GHANEM APRN, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29055 CLEMENS RD STE A
WESTLAKE OH
44145-1135
US

IV. Provider business mailing address

29055 CLEMENS RD STE A
WESTLAKE OH
44145-1135
US

V. Phone/Fax

Practice location:
  • Phone: 216-450-1613
  • Fax: 216-450-1614
Mailing address:
  • Phone: 216-450-1613
  • Fax: 216-450-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.424034
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0027191
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0027191
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: