Provider Demographics
NPI:1659088631
Name:WAIT, FANCY DANIELLE
Entity Type:Individual
Prefix:
First Name:FANCY
Middle Name:DANIELLE
Last Name:WAIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FANCY
Other - Middle Name:DANIELLE
Other - Last Name:MCKENZIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4972 FRANKLIN RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-8831
Mailing Address - Country:US
Mailing Address - Phone:937-509-4022
Mailing Address - Fax:
Practice Address - Street 1:4972 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-8831
Practice Address - Country:US
Practice Address - Phone:937-509-4022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTS993684376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty