Provider Demographics
NPI:1093019622
Name:FOSU, REGINA A
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:A
Last Name:FOSU
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 1:7883 CHAPEL STONE RD
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8341
Mailing Address - Country:US
Mailing Address - Phone:614-863-5195
Mailing Address - Fax:614-863-5195
Practice Address - Street 1:7883 CHAPEL STONE RD
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-8341
Practice Address - Country:US
Practice Address - Phone:614-863-5195
Practice Address - Fax:614-863-5195
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH136346164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse