Provider Demographics
NPI:1750513404
Name:SMITH, SUSAN ANNETTE (LPN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANNETTE
Last Name:SMITH
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 1:44 WARD KOEBEL RD
Mailing Address - Street 2:
Mailing Address - City:OREGONIA
Mailing Address - State:OH
Mailing Address - Zip Code:45054-9467
Mailing Address - Country:US
Mailing Address - Phone:937-289-1309
Mailing Address - Fax:
Practice Address - Street 1:44 WARD KOEBEL RD
Practice Address - Street 2:
Practice Address - City:OREGONIA
Practice Address - State:OH
Practice Address - Zip Code:45054-9467
Practice Address - Country:US
Practice Address - Phone:937-289-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.135338164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2775322Medicaid