Provider Demographics
NPI:1407473689
Name:BLYTHEWOOD, DEBRA RENEE
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:RENEE
Last Name:BLYTHEWOOD
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 1:1490 E 193RD ST APT 247
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1349
Mailing Address - Country:US
Mailing Address - Phone:216-338-8392
Mailing Address - Fax:
Practice Address - Street 1:1490 E 193RD ST APT 247
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-1349
Practice Address - Country:US
Practice Address - Phone:216-338-8392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2762809Medicaid