Provider Demographics
NPI:1073280178
Name:LIDDELL, GLORIA JEAN
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:JEAN
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3529 E. 118TH STREET
Mailing Address - Street 2:SAME
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105
Mailing Address - Country:US
Mailing Address - Phone:216-752-3188
Mailing Address - Fax:
Practice Address - Street 1:3529 E. 118TH STREET
Practice Address - Street 2:SAME
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105
Practice Address - Country:US
Practice Address - Phone:216-752-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home