Provider Demographics
NPI:1104109164
Name:TATE, JACQUELINE (RN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TATE
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 1:23402 GREENLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1426
Mailing Address - Country:US
Mailing Address - Phone:216-381-0005
Mailing Address - Fax:
Practice Address - Street 1:23402 GREENLAWN AVE
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-1426
Practice Address - Country:US
Practice Address - Phone:216-381-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH366811163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse