Healthcare Provider Details

I. General information

NPI: 1215128830
Provider Name (Legal Business Name): JUDITH L SANISLOW-HALL LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13445 DIAGONAL RD
LAGRANGE OH
44050-9723
US

IV. Provider business mailing address

13445 DIAGONAL RD
LAGRANGE OH
44050-9723
US

V. Phone/Fax

Practice location:
  • Phone: 440-225-9843
  • Fax:
Mailing address:
  • Phone: 440-225-9843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN098305
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: