=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669062717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE WICHERT GCNS-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2021
-----------------------------------------------------
Last Update Date | 01/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6801 BRECKSVILLE RD
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44131-5032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-704-6558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9497 N BEXLEY DR
-----------------------------------------------------
City | STRONGSVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44136-8841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-785-3051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Clinical Nurse Specialist
-----------------------------------------------------
License Number | APN.CNS.17151
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------