=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104437003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE BOUCHAHINE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2020
-----------------------------------------------------
Last Update Date | 08/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9500 EUCLID AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44195-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-444-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2757 COVENTRY DR
-----------------------------------------------------
City | PARMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44134-5633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-429-2851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.0027348
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------