Basic Information
Provider Information | |||||||||
NPI: | 1669486387 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAULORICO | ||||||||
FirstName: | JOHANNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
Address2: | 1ST FLOOR | ||||||||
City: | SHAKER HTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441225203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162866260 | ||||||||
FaxNumber: | 2162866341 | ||||||||
Practice Location | |||||||||
Address1: | 11100 EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441061716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2168447330 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2006 | ||||||||
LastUpdateDate: | 05/19/2008 | ||||||||
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 | 367500000X | RN217978 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 000000221166 | 01 | OH | UNISON | OTHER | 000000515997 | 01 | OH | ANTHEM | OTHER | 0583328 | 01 | OH | BCMH | OTHER | 430050956 | 01 | OH | RAILROAD MEDICARE | OTHER | 2306034 | 05 | OH |   | MEDICAID | 415008 | 01 | OH | WELLCARE MEDICAID | OTHER | 750905 | 01 | OH | BUCKEYE MEDICAID | OTHER | 7960351 | 01 | OH | AETNA | OTHER | P00405855 | 01 | OH | MEDICARE RAILROAD | OTHER |