Provider Demographics
NPI:1568735025
Name:EATON, MARJORIE SUE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:SUE
Last Name:EATON
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 1:2504 LITTLE YORK RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-1630
Mailing Address - Country:US
Mailing Address - Phone:937-478-1302
Mailing Address - Fax:937-454-0667
Practice Address - Street 1:2504 LITTLE YORK RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-1630
Practice Address - Country:US
Practice Address - Phone:937-478-1302
Practice Address - Fax:937-454-0667
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH115934164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5708756OtherOHIO I/O WAIVER