Provider Demographics
NPI:1588060321
Name:FETZNER, JILLIAN TAIT (NP-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:TAIT
Last Name:FETZNER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:TAIT
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:10685 CARNEGIE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106
Mailing Address - Country:US
Mailing Address - Phone:216-445-7634
Mailing Address - Fax:216-444-3474
Practice Address - Street 1:10685 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:216-445-7634
Practice Address - Fax:216-444-3474
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA16124363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0115025Medicaid