Healthcare Provider Details

I. General information

NPI: 1376006940
Provider Name (Legal Business Name): SHARA PETRICE' WASHINGTON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8120 GARNET DR
CENTERVILLE OH
45458-2141
US

IV. Provider business mailing address

8120 GARNET DR
DAYTON OH
45458-2141
US

V. Phone/Fax

Practice location:
  • Phone: 833-510-4357
  • Fax:
Mailing address:
  • Phone: 513-834-7063
  • Fax: 513-873-1567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.163751.MEDS-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: