Provider Demographics
NPI:1386300572
Name:CRUZ, JULISSA (RN)
Entity type:Individual
Prefix:
First Name:JULISSA
Middle Name:
Last Name:CRUZ
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 1:3011 CHERYLANE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-3217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3011 CHERYLANE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-3217
Practice Address - Country:US
Practice Address - Phone:614-353-8126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH488597163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3682279Medicaid