Healthcare Provider Details

I. General information

NPI: 1093850760
Provider Name (Legal Business Name): JENNIFER DIANE CORISTIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 MONTROSE CIR
BOARDMAN OH
44512-1649
US

IV. Provider business mailing address

12 MONTROSE CIR
BOARDMAN OH
44512-1649
US

V. Phone/Fax

Practice location:
  • Phone: 330-501-7986
  • Fax:
Mailing address:
  • Phone: 330-501-7986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number262444
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: