Provider Demographics
NPI:1205419496
Name:HANSELMAN, CONNIE SUE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
Last Name:HANSELMAN
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 1:11099 SMOKY ROW RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45121-9528
Mailing Address - Country:US
Mailing Address - Phone:937-378-4961
Mailing Address - Fax:
Practice Address - Street 1:11156 SMOKY ROW RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-8214
Practice Address - Country:US
Practice Address - Phone:937-378-6683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide