Basic Information
| Provider Information | |||||||||
| NPI: | 1205105012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IPPOLITO | ||||||||
| FirstName: | TATIANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IPPOLITO | ||||||||
| OtherFirstName: | TATIANA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20600 CHAGRIN BLVD STE 620 | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167514762 | ||||||||
| FaxNumber: | 2167515894 | ||||||||
| Practice Location | |||||||||
| Address1: | 20600 CHAGRIN BLVD STE 620 | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167514762 | ||||||||
| FaxNumber: | 2167515894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2011 | ||||||||
| LastUpdateDate: | 09/18/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WH0200X | RN.37288A | OH | Y | Nursing Service Providers | Registered Nurse | Home Health |
No ID Information.