Provider Demographics
NPI:1003543612
Name:PERNELL, REECAUSETTER
Entity Type:Individual
Prefix:
First Name:REECAUSETTER
Middle Name:
Last Name:PERNELL
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 1:863 PROUTY AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-3262
Mailing Address - Country:US
Mailing Address - Phone:404-759-0552
Mailing Address - Fax:
Practice Address - Street 1:863 PROUTY AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43609-3262
Practice Address - Country:US
Practice Address - Phone:404-759-0552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty