Provider Demographics
NPI:1639778772
Name:TEBBE, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:TEBBE
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 1:7800 HOENIE RD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-9431
Mailing Address - Country:US
Mailing Address - Phone:419-305-2000
Mailing Address - Fax:
Practice Address - Street 1:626 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1537
Practice Address - Country:US
Practice Address - Phone:419-305-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH347C00000XMedicaid
OH376J00000XMedicaid