Provider Demographics
NPI:1326280777
Name:GOLDEN YEARS NURSE PRACTITIONER SERVICES LLC
Entity Type:Organization
Organization Name:GOLDEN YEARS NURSE PRACTITIONER SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERIDAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HULL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:330-389-1449
Mailing Address - Street 1:3107 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-8930
Mailing Address - Country:US
Mailing Address - Phone:330-389-1449
Mailing Address - Fax:
Practice Address - Street 1:3107 LOVERS LN
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-8930
Practice Address - Country:US
Practice Address - Phone:330-389-1449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2947744Medicaid
OH2947744Medicaid