Provider Demographics
NPI:1457817256
Name:OBENOUR, SUSIE
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:OBENOUR
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 1:5522 NEW LONDON RD
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-8901
Mailing Address - Country:US
Mailing Address - Phone:440-813-8111
Mailing Address - Fax:440-536-5015
Practice Address - Street 1:5522 NEW LONDON RD
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-8901
Practice Address - Country:US
Practice Address - Phone:440-813-8111
Practice Address - Fax:440-536-5015
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-17
Last Update Date:2019-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401673700714374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide