Provider Demographics
NPI:1699437772
Name:GENDRAW, CARMALITA R
Entity type:Individual
Prefix:
First Name:CARMALITA
Middle Name:R
Last Name:GENDRAW
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 1:22140 EUCLID AVE APT 508
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1614
Mailing Address - Country:US
Mailing Address - Phone:216-704-6640
Mailing Address - Fax:
Practice Address - Street 1:22140 EUCLID AVE APT 508
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-1614
Practice Address - Country:US
Practice Address - Phone:216-704-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRU778241172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver