Healthcare Provider Details

I. General information

NPI: 1952522682
Provider Name (Legal Business Name): SHARON LESLIE KITSONAS CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11741 COVENTRY AVE
PICKERINGTON OH
43147-8488
US

IV. Provider business mailing address

11741 COVENTRY AVE
PICKERINGTON OH
43147-8488
US

V. Phone/Fax

Practice location:
  • Phone: 614-868-0546
  • Fax: 614-868-8969
Mailing address:
  • Phone: 614-868-0546
  • Fax: 614-868-8969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number00006443
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: