Provider Demographics
NPI:1265841654
Name:RETHERFORD, EMMA
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:RETHERFORD
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 1:2517 JOHNSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CENTERBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43011-9031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2517 JOHNSTOWN RD
Practice Address - Street 2:
Practice Address - City:CENTERBURG
Practice Address - State:OH
Practice Address - Zip Code:43011-9031
Practice Address - Country:US
Practice Address - Phone:740-398-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08141172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker