Provider Demographics
NPI:1780348375
Name:FAWCETT, ANA
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:
Last Name:FAWCETT
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 1:604 S MCKENZIE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-4168
Mailing Address - Country:US
Mailing Address - Phone:740-398-8147
Mailing Address - Fax:
Practice Address - Street 1:604 S MCKENZIE ST APT 2
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-4168
Practice Address - Country:US
Practice Address - Phone:740-398-8147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4204789Medicaid