Provider Demographics
NPI:1699813725
Name:PANGBORN, VIVIAN SUE
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:SUE
Last Name:PANGBORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 HARRIS DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-8642
Mailing Address - Country:US
Mailing Address - Phone:740-387-0707
Mailing Address - Fax:
Practice Address - Street 1:1842 HARRIS DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-8642
Practice Address - Country:US
Practice Address - Phone:740-387-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1699813725374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2436331Medicare UPIN