Provider Demographics
NPI:1083827141
Name:BROSSMAN, ROLLIN LOUIS (LPN)
Entity Type:Individual
Prefix:
First Name:ROLLIN
Middle Name:LOUIS
Last Name:BROSSMAN
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 COLUMBUS AVE APT D
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-3246
Mailing Address - Country:US
Mailing Address - Phone:937-360-2003
Mailing Address - Fax:
Practice Address - Street 1:3375 COLUMBUS AVE APT D
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-3246
Practice Address - Country:US
Practice Address - Phone:937-360-2003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN. 119618 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2705157Medicaid