Healthcare Provider Details

I. General information

NPI: 1851883177
Provider Name (Legal Business Name): JUAHARA KNIESS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 NORTHCUTT PL
DAYTON OH
45414-3840
US

IV. Provider business mailing address

6169 GREENFIELD WAY
HUBER HEIGHTS OH
45424-1318
US

V. Phone/Fax

Practice location:
  • Phone: 937-496-2020
  • Fax:
Mailing address:
  • Phone: 937-818-8233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN-086-307-MEDS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: