MEDICARE: MS. NICOLE LEE REIS-EIBARA APRN

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	363LF0000X	Family Nurse Practitioner	AP61007025	WA
2	363LF0000X	Family Nurse Practitioner	CNP24682	OH

General Provider Information

NPI Number	:	1134782543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NICOLE LEE REIS-EIBARA APRN

Provider Business Mailing Address
First Line	:	2638 EASTON ST NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44721-2655
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2638 EASTON ST NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44721-2655
Country	:	US
Telephone Number	:	330-494-6480
Fax Number	:

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

Provider Enumeration Date	:	04/22/2019
Last Update Date	:	09/15/2023

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