Provider Demographics
NPI:1508281767
Name:CLOSE, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:CLOSE
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 1:4666 PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-8923
Mailing Address - Country:US
Mailing Address - Phone:419-217-4070
Mailing Address - Fax:
Practice Address - Street 1:500 W STATE ST STE A
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2580
Practice Address - Country:US
Practice Address - Phone:419-332-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 168610163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool