Healthcare Provider Details

I. General information

NPI: 1932318417
Provider Name (Legal Business Name): JACQUELINE E FYOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4777 CANFIELD RD
CANFIELD OH
44406-9350
US

IV. Provider business mailing address

4777 CANFIELD RD
CANFIELD OH
44406-9350
US

V. Phone/Fax

Practice location:
  • Phone: 330-793-6429
  • Fax: 330-793-6429
Mailing address:
  • Phone: 330-793-6429
  • Fax: 330-793-6429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number2436233
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: