Provider Demographics
NPI:1619603750
Name:STETTNISCH, NICOLE ANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:STETTNISCH
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 1:7232 JUSTIN WAY
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4881
Mailing Address - Country:US
Mailing Address - Phone:440-578-8200
Mailing Address - Fax:
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4115
Practice Address - Country:US
Practice Address - Phone:440-578-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-30
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator