Provider Demographics
NPI:1447423330
Name:POPROCKI-JAKE, LINDA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:POPROCKI-JAKE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38585 THORTON LANE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011
Mailing Address - Country:US
Mailing Address - Phone:440-856-9063
Mailing Address - Fax:440-891-1361
Practice Address - Street 1:38585 THORTON LN
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-5208
Practice Address - Country:US
Practice Address - Phone:440-856-9063
Practice Address - Fax:440-891-1361
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN111388164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2586376Medicaid