Provider Demographics
NPI:1912195082
Name:DETTRA, SUSAN L (LPN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:DETTRA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54005 SARAHSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43772-9611
Mailing Address - Country:US
Mailing Address - Phone:740-680-7237
Mailing Address - Fax:
Practice Address - Street 1:54005 SARAHSVILLE RD
Practice Address - Street 2:
Practice Address - City:PLEASANT CITY
Practice Address - State:OH
Practice Address - Zip Code:43772-9611
Practice Address - Country:US
Practice Address - Phone:740-680-7237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-13
Last Update Date:2007-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN078189164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse