Basic Information
| Provider Information | |||||||||
| NPI: | 1780100040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KODIYAN OUSEPH | ||||||||
| FirstName: | SHERLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13000 AUBURN RD | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440249337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 14402799357 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5592 BROADVIEW RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | PARMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441341677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167415200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2017 | ||||||||
| LastUpdateDate: | 08/18/2017 | ||||||||
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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 | 363L00000X | AG0217016 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 02170168 | 05 | OH | MEDICAID | AG0217016 | 01 | OH | MEDICARE | OTHER |