1003138314 NPI number — MS. LEAH REBBECA STALLWORTH APRN

Table of content: MS. LEAH REBBECA STALLWORTH APRN (NPI 1003138314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003138314 NPI number — MS. LEAH REBBECA STALLWORTH APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STALLWORTH
Provider First Name:
LEAH
Provider Middle Name:
REBBECA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STALLWORTH
Provider Other First Name:
LEAH
Provider Other Middle Name:
REBBECA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1003138314
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19530 EUCLID AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUCLID
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44117-1486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-243-5589
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19530 EUCLID AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUCLID
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44117-1486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-243-5589
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  0029728 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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