Provider Demographics
NPI:1699432757
Name:MELLERT, LETITIA ANN
Entity type:Individual
Prefix:
First Name:LETITIA
Middle Name:ANN
Last Name:MELLERT
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 1:140 N SPRING GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-1919
Mailing Address - Country:US
Mailing Address - Phone:330-990-9578
Mailing Address - Fax:
Practice Address - Street 1:140 N SPRING GROVE ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1919
Practice Address - Country:US
Practice Address - Phone:330-990-9578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0463689Medicaid