Provider Demographics
NPI:1336164714
Name:SNIDER-FULLER, REBECCA R (PCNS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:R
Last Name:SNIDER-FULLER
Suffix:
Gender:F
Credentials:PCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6835 BROADWAY AVE
Mailing Address - Street 2:METROHEALTH BROADWAY HEALTH CENTER
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-1313
Mailing Address - Country:US
Mailing Address - Phone:216-957-1807
Mailing Address - Fax:
Practice Address - Street 1:6835 BROADWAY AVE
Practice Address - Street 2:METROHEALTH BROADWAY HEALTH CENTER
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-1313
Practice Address - Country:US
Practice Address - Phone:216-957-1807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS02942364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2209292Medicaid
OHSNNS75001Medicare ID - Type Unspecified
OH2209292Medicaid