Basic Information
| Provider Information | |||||||||
| NPI: | 1669979175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STROUD | ||||||||
| FirstName: | EVALEIGH | ||||||||
| MiddleName: | NICOLE | ||||||||
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| OtherLastName: | STROUD | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3928 HARROWSFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435603561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196996362 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2150 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192917919 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2018 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.