MEDICARE: BENISHA NICKELBERRY-PRUITT

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	163W00000X	Registered Nurse	358601	OH

General Provider Information

NPI Number	:	1427376227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENISHA NICKELBERRY-PRUITT

Provider Business Mailing Address
First Line	:	3792 LOWELL RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-2048
Country	:	US
Telephone Number	:	216-780-5481
Fax Number	:	216-291-2024

Provider Business Practice Location Address
First Line	:	3792 LOWELL RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-2048
Country	:	US
Telephone Number	:	216-780-5481
Fax Number	:	216-291-2024

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

Provider Enumeration Date	:	05/04/2010
Last Update Date	:	05/04/2010

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