Provider Demographics
NPI:1851724926
Name:VIDALIS, MARTHA EMILY (RN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:EMILY
Last Name:VIDALIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-2913
Mailing Address - Country:US
Mailing Address - Phone:216-634-2355
Mailing Address - Fax:
Practice Address - Street 1:6601 FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-2913
Practice Address - Country:US
Practice Address - Phone:216-634-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN200804163W00000X
OHRN OH200804163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163W00000XNursing Service ProvidersRegistered Nurse