Provider Demographics
NPI:1871189779
Name:CASSISDY, CARRIE RENEE
Entity Type:Individual
Prefix:MISS
First Name:CARRIE
Middle Name:RENEE
Last Name:CASSISDY
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 1:2122 UTAH CT NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-3732
Mailing Address - Country:US
Mailing Address - Phone:330-685-0249
Mailing Address - Fax:
Practice Address - Street 1:2122 UTAH CT NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-3732
Practice Address - Country:US
Practice Address - Phone:330-685-0249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRL543721374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0276852Medicaid