Provider Demographics
NPI:1417014051
Name:WHITENACK, CONNIE MARIE
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:MARIE
Last Name:WHITENACK
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 1:880 W MORGAN RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:44047-8130
Mailing Address - Country:US
Mailing Address - Phone:440-645-6961
Mailing Address - Fax:440-998-7899
Practice Address - Street 1:5772 DIBBLE RD APT D
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44048-9802
Practice Address - Country:US
Practice Address - Phone:440-224-1987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2497016Medicaid