MEDICARE: EBONY LUV WEATHERSPOON

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	164W00000X	Licensed Practical Nurse	162122	OH

General Provider Information

NPI Number	:	1497267231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY LUV WEATHERSPOON

Provider Business Mailing Address
First Line	:	12321 WOODSIDE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-2418
Country	:	US
Telephone Number	:	216-849-3412
Fax Number	:

Provider Business Practice Location Address
First Line	:	12321 WOODSIDE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-2418
Country	:	US
Telephone Number	:	216-849-3412
Fax Number	:

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

Provider Enumeration Date	:	11/02/2017
Last Update Date	:	11/02/2017

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Directions to “ EBONY LUV WEATHERSPOON ” Practice Location

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