=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912529397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. GREGORY MALCOLM HIGGINS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2020
-----------------------------------------------------
Last Update Date | 05/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19934 STATE ROUTE 58
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44090-9468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-310-6637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19934 STATE ROUTE 58
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44090-9468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-310-6637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | APRN.CNP.026699
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------