Provider Demographics
NPI:1912237728
Name:FOGT, KATHRYN SUE (LPN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:SUE
Last Name:FOGT
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 1:586 GRAMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-5521
Mailing Address - Country:US
Mailing Address - Phone:937-559-4763
Mailing Address - Fax:
Practice Address - Street 1:8355 FLICK RD
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-8412
Practice Address - Country:US
Practice Address - Phone:937-405-1980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN055669164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse