Provider Demographics
NPI:1750779096
Name:WIDENER, CARLA
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:WIDENER
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 1:612 E 222ND ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-2024
Mailing Address - Country:US
Mailing Address - Phone:216-780-0686
Mailing Address - Fax:
Practice Address - Street 1:612 E 222ND ST
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-2024
Practice Address - Country:US
Practice Address - Phone:216-780-0686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN:103552164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse