Healthcare Provider Details

I. General information

NPI: 1598213456
Provider Name (Legal Business Name): TINA KERN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W MAIN ST
ALVORDTON OH
43501-9763
US

IV. Provider business mailing address

109 W MAIN ST
ALVORDTON OH
43501-9763
US

V. Phone/Fax

Practice location:
  • Phone: 419-924-2029
  • Fax:
Mailing address:
  • Phone: 419-924-2029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.096228.MEDS-IV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: