Healthcare Provider Details

I. General information

NPI: 1467611426
Provider Name (Legal Business Name): CARLA S TATE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28820 CHAGRIN BLVD APT.216
WOODMERE OH
44122-4641
US

IV. Provider business mailing address

28820 CHAGRIN BLVD APT 219
WOODMERE OH
44122-4641
US

V. Phone/Fax

Practice location:
  • Phone: 216-772-7725
  • Fax:
Mailing address:
  • Phone: 216-772-7725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberRH042828
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number340388
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: