=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003680851
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE PEMPTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2023
-----------------------------------------------------
Last Update Date | 11/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3633 LYNNFIELD RD # DN
-----------------------------------------------------
City | SHAKER HTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-5111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-268-7664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3633 LYNNFIELD RD # DN
-----------------------------------------------------
City | SHAKER HTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-5111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-268-7664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | RJ810051
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------