Healthcare Provider Details

I. General information

NPI: 1508281767
Provider Name (Legal Business Name): CONNIE CLOSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W STATE ST STE A
FREMONT OH
43420-2580
US

IV. Provider business mailing address

4666 PRAIRIE RD
BELLEVUE OH
44811-8923
US

V. Phone/Fax

Practice location:
  • Phone: 419-332-6454
  • Fax:
Mailing address:
  • Phone: 419-217-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN 168610
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: