Provider Demographics
NPI:1578062345
Name:DRAKE, REGINA LYNN (STNA)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:LYNN
Last Name:DRAKE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 MANOR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-4728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18903 LONGVIEW AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-1624
Practice Address - Country:US
Practice Address - Phone:216-581-9254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400321000104374U00000X
OH101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0212274Medicaid