Provider Demographics
NPI:1972059624
Name:FRALEY, CONNIE SUE (LPN162235MEDS-IV)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:SUE
Last Name:FRALEY
Suffix:
Gender:F
Credentials:LPN162235MEDS-IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 E LAKE SHORE DR APT 23
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45237-1553
Mailing Address - Country:US
Mailing Address - Phone:937-509-5244
Mailing Address - Fax:
Practice Address - Street 1:8958 PIGEON ROOST RD.
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133
Practice Address - Country:US
Practice Address - Phone:937-509-5244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162235164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0191235Medicaid