Provider Demographics
NPI:1013499938
Name:FOFANAH, ELIZABETH MAY (LPN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MAY
Last Name:FOFANAH
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 1:3478 HAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-6049
Mailing Address - Country:US
Mailing Address - Phone:614-589-4945
Mailing Address - Fax:
Practice Address - Street 1:3478 HAIL RIDGE DR
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-6049
Practice Address - Country:US
Practice Address - Phone:614-589-4945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.155587.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1922368166Medicaid