Healthcare Provider Details

I. General information

NPI: 1609705987
Provider Name (Legal Business Name): KISHAE FORTHEASE WOFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 BELLFLOWER AVE SW
CANTON OH
44710-2015
US

IV. Provider business mailing address

1219 BELLFLOWER AVE SW
CANTON OH
44710-2015
US

V. Phone/Fax

Practice location:
  • Phone: 330-437-7362
  • Fax:
Mailing address:
  • Phone: 330-437-7362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberAPP-000044142
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: