Provider Demographics
NPI:1871921676
Name:ILSE, MARIE (FNP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:ILSE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22500 SHELBURNE RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-2055
Mailing Address - Country:US
Mailing Address - Phone:267-549-4985
Mailing Address - Fax:
Practice Address - Street 1:90500 EUCLID AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-2055
Practice Address - Country:US
Practice Address - Phone:216-444-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127950363LF0000X
SC18537363LF0000X
FL9469719363LF0000X
OH0030457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily