Basic Information
| Provider Information | |||||||||
| NPI: | 1720530181 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAST RESPONSE NURSE PRACTITIONERS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSPRING NURSE PRACTITIONERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3905 OBERLIN AVE | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440532853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405417790 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 15800 DETROIT AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441073748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162268700 | ||||||||
| FaxNumber: | 2162213171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2016 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TOETZ | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4409306686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 0193892 | 05 | OH | MEDICAID |