Healthcare Provider Details

I. General information

NPI: 1164809745
Provider Name (Legal Business Name): SAVANNA LEE MAGUIRE STNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2015
Last Update Date: 05/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2763 HENLEY COMSTOCK RD
OTWAY OH
45657-9076
US

IV. Provider business mailing address

2763 HENLEY COMSTOCK RD
OTWAY OH
45657-9076
US

V. Phone/Fax

Practice location:
  • Phone: 740-464-6002
  • Fax:
Mailing address:
  • Phone: 740-464-6002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number401623480314
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: