Provider Demographics
NPI:1821508342
Name:SIDWELL, JANE A
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:SIDWELL
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 1:20265 EMERY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH RANDALL
Mailing Address - State:OH
Mailing Address - Zip Code:44128-4122
Mailing Address - Country:US
Mailing Address - Phone:440-523-9966
Mailing Address - Fax:216-584-2895
Practice Address - Street 1:8064 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6153
Practice Address - Country:US
Practice Address - Phone:440-523-9966
Practice Address - Fax:216-584-2895
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNS.16810364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology