Provider Demographics
NPI:1770111213
Name:RAK, KATHLEEN M
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:RAK
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 1:7218 AMES RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-6402
Mailing Address - Country:US
Mailing Address - Phone:440-454-5337
Mailing Address - Fax:
Practice Address - Street 1:7218 AMES RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-6402
Practice Address - Country:US
Practice Address - Phone:440-454-5337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0063878251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0063878Medicaid