Provider Demographics
NPI:1194023267
Name:JEANDERVIN, CONNIE J (RN)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:J
Last Name:JEANDERVIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-1302
Mailing Address - Country:US
Mailing Address - Phone:330-364-6184
Mailing Address - Fax:
Practice Address - Street 1:524 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-1302
Practice Address - Country:US
Practice Address - Phone:330-364-6184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.176450163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse