Provider Demographics
NPI:1124565502
Name:BALES, JODY (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:
Last Name:BALES
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 1:569 S COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-5699
Mailing Address - Country:US
Mailing Address - Phone:937-376-3991
Mailing Address - Fax:
Practice Address - Street 1:569 S COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-5699
Practice Address - Country:US
Practice Address - Phone:937-376-3991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.087324.MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse