Provider Demographics
NPI:1093731903
Name:CHURCH, PAUL (RN)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:CHURCH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 55TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-3904
Mailing Address - Country:US
Mailing Address - Phone:330-966-0814
Mailing Address - Fax:330-305-0815
Practice Address - Street 1:1120 55TH ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-3904
Practice Address - Country:US
Practice Address - Phone:330-966-0814
Practice Address - Fax:330-305-0815
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN239290163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2292728Medicaid