Provider Demographics
NPI:1326653767
Name:CROSS, KATHERINE R
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:R
Last Name:CROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:R
Other - Last Name:DONNELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1509 PARKMAN RD NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-2160
Mailing Address - Country:US
Mailing Address - Phone:915-315-0185
Mailing Address - Fax:
Practice Address - Street 1:1509 PARKMAN RD NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2160
Practice Address - Country:US
Practice Address - Phone:915-315-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0411157Medicaid