Provider Demographics
NPI:1508510363
Name:SUDIA, NICOLE LEE (INDEPENDENT PROVIDER)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:SUDIA
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 AETNA ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-3752
Mailing Address - Country:US
Mailing Address - Phone:234-232-4417
Mailing Address - Fax:
Practice Address - Street 1:6602 COVINGTON CV
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-8161
Practice Address - Country:US
Practice Address - Phone:234-232-4417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1501267251E00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No251E00000XAgenciesHome Health