MEDICARE: KATHLEEN SIBYL KRESS FARRELL CPNP

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	208000000X	Pediatrics Physician	RN356026	OH
2	363LP0200X	Pediatric Nurse Practitioner	APRN.CNP.022438	OH

General Provider Information

NPI Number	:	1376170381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN SIBYL KRESS FARRELL CPNP

Provider Business Mailing Address
First Line	:	14701 DETROIT AVE STE 250
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-4109
Country	:	US
Telephone Number	:	216-221-5901
Fax Number	:	216-221-5881

Provider Business Practice Location Address
First Line	:	14701 DETROIT AVE STE 250
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-4109
Country	:	US
Telephone Number	:	216-221-5901
Fax Number	:	216-221-5881

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

Provider Enumeration Date	:	03/27/2020
Last Update Date	:	11/10/2021

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