Provider Demographics
NPI:1760926042
Name:NUSSBAUM, MONICA JOY (CNA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:JOY
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 6TH ST NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2427
Mailing Address - Country:US
Mailing Address - Phone:330-763-3807
Mailing Address - Fax:
Practice Address - Street 1:509 6TH ST NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2427
Practice Address - Country:US
Practice Address - Phone:330-763-3807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3701-18-24374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0179899Medicaid