=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588783054
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERYL ANN HERTRICK PNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 01/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11100 EUCLID AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44106-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-844-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3605 WARRENSVILLE CENTER RD
-----------------------------------------------------
City | SHAKER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-5203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-286-6296
-----------------------------------------------------
Fax | 216-286-6341
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | COA 10425 NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------