Provider Demographics
NPI:1760692545
Name:DIEHL, JEFFERY W (LPN)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:W
Last Name:DIEHL
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:328 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:FAIRPORT HARBOR
Practice Address - State:OH
Practice Address - Zip Code:44077-5708
Practice Address - Country:US
Practice Address - Phone:440-352-0617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.124633 MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2704596Medicaid