Basic Information
| Provider Information | |||||||||
| NPI: | 1417941428 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETHEART | ||||||||
| FirstName: | ROSEMARY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26908 DETROIT RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441452398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406171823 | ||||||||
| FaxNumber: | 4406170884 | ||||||||
| Practice Location | |||||||||
| Address1: | 28105 CLEMENS RD | ||||||||
| Address2: | BLDG 3 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441451100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407884500 | ||||||||
| FaxNumber: | 4408354376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN167684 | OH | N | Nursing Service Providers | Registered Nurse | 363L00000X | COA.03116-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2577966 | 05 | OH | MEDICAID |