Provider Demographics
NPI:1609894997
Name:CHOM, MICHELLE DAWN (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
Last Name:CHOM
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 1:620 DAWN RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-3253
Mailing Address - Country:US
Mailing Address - Phone:440-428-9484
Mailing Address - Fax:440-428-9484
Practice Address - Street 1:620 DAWN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-3253
Practice Address - Country:US
Practice Address - Phone:440-428-9484
Practice Address - Fax:440-428-9484
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH112853164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2488919Medicaid