Provider Demographics
NPI:1073917985
Name:TAMI PERNELL
Entity Type:Organization
Organization Name:TAMI PERNELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:PERNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-210-2725
Mailing Address - Street 1:168 E STATE ROUTE 296
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-9325
Mailing Address - Country:US
Mailing Address - Phone:937-210-2725
Mailing Address - Fax:
Practice Address - Street 1:168 E STATE ROUTE 296
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-9325
Practice Address - Country:US
Practice Address - Phone:937-210-2725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1286423140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric