MEDICARE: KELLY R CERVENKA CNP

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	RN211663	OH
2	363L00000X	Nurse Practitioner	COA.04944-NP	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871587808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY R CERVENKA CNP

Provider Business Mailing Address
First Line	:	10275 CLIPPER CV
Second Line	:
City	:	REMINDERVILLE
State	:	OH
Zip	:	44202-9042
Country	:	US
Telephone Number	:	330-562-2630
Fax Number	:

Provider Business Practice Location Address
First Line	:	4229 PEARL RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44109-4218
Country	:	US
Telephone Number	:	216-205-4026
Fax Number	:	216-205-4032

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

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	08/30/2013

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