Provider Demographics
NPI:1649615204
Name:GATES, MYRTLE TAMMIE
Entity type:Individual
Prefix:MRS
First Name:MYRTLE
Middle Name:TAMMIE
Last Name:GATES
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 1:3115 LIVINGSTON ROAD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120
Mailing Address - Country:US
Mailing Address - Phone:216-355-9496
Mailing Address - Fax:
Practice Address - Street 1:3115 LIVINGSTON RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-3240
Practice Address - Country:US
Practice Address - Phone:216-355-9496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374399163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse