{
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"FirstLineMailingAddress": "455 EAGLE TRCE",
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"MailingAddressCityName": "MAYFIELD HEIGHTS",
"MailingAddressStateName": "OH",
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"MailingAddressCountryCode": "US",
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"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "5010 MAYFIELD RD STE 116",
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"PracticeLocationAddressCityName": "LYNDHURST",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "216-273-9362",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "07/19/2023",
"LastUpdateDate": "07/19/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
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"Taxonomies": {
"Taxonomy": {
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"LicenseNumber": "A.02258",
"LicenseNumberStateCode": "OH",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}