Healthcare Provider Details

I. General information

NPI: 1215606959
Provider Name (Legal Business Name): DEBRA JEAN SORG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 CROCKER RD
WESTLAKE OH
44145-6329
US

IV. Provider business mailing address

5800 LANDERBROOK DR STE 100
MAYFIELD HEIGHTS OH
44124-6510
US

V. Phone/Fax

Practice location:
  • Phone: 440-588-8005
  • Fax: 440-835-4790
Mailing address:
  • Phone: 440-443-0423
  • Fax: 440-443-0414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0029461
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: