Provider Demographics
NPI:1083955652
Name:FEDORKO, ANNA (LPN)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:FEDORKO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 EASTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:OH
Mailing Address - Zip Code:44041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:731 EASTWOOD ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-1722
Practice Address - Country:US
Practice Address - Phone:440-466-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 112686164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse