Provider Demographics
NPI:1417040759
Name:MANDEL, LAURIE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:MANDEL
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 1:2503 RUBYVALE RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4619
Mailing Address - Country:US
Mailing Address - Phone:216-291-4089
Mailing Address - Fax:216-291-9861
Practice Address - Street 1:2503 RUBYVALE RD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HTS
Practice Address - State:OH
Practice Address - Zip Code:44118-4619
Practice Address - Country:US
Practice Address - Phone:216-406-4323
Practice Address - Fax:216-291-9861
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA-NP-02671363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2249758Medicaid
OH000000372969OtherANTHEM
OHQ27820Medicare UPIN