MEDICARE: MARY ETTA NICHOLS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		OH

General Provider Information

NPI Number	:	1093348476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ETTA NICHOLS

Provider Business Mailing Address
First Line	:	2231 N TAYLOR RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44112-3044
Country	:	US
Telephone Number	:	216-441-2496
Fax Number	:	216-634-9611

Provider Business Practice Location Address
First Line	:	2231 N TAYLOR RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44112-3044
Country	:	US
Telephone Number	:	216-441-2496
Fax Number	:	216-634-9611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2020
Last Update Date	:	02/13/2020

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