Provider Demographics
NPI:1619574852
Name:FUSSELMAN, BRENT FRANK
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:FRANK
Last Name:FUSSELMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6643 FIRST AVE.
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44003
Mailing Address - Country:US
Mailing Address - Phone:440-645-9543
Mailing Address - Fax:
Practice Address - Street 1:6643 FIRST AVE.
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:OH
Practice Address - Zip Code:44003
Practice Address - Country:US
Practice Address - Phone:440-645-9543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker