Provider Demographics
NPI:1689260366
Name:FETZER, SUSAN ANN (LPN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:FETZER
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 1:801 E WASHINGTON ST STE 150
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3336
Mailing Address - Country:US
Mailing Address - Phone:330-722-1069
Mailing Address - Fax:330-764-9712
Practice Address - Street 1:801 E WASHINGTON ST STE 150
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3336
Practice Address - Country:US
Practice Address - Phone:330-722-1069
Practice Address - Fax:330-764-9712
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH145719164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse