Healthcare Provider Details

I. General information

NPI: 1336076058
Provider Name (Legal Business Name): DONNA JEAN PACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 S FOSTORIA AVE
SPRINGFIELD OH
45505-1406
US

IV. Provider business mailing address

147 S FOSTORIA AVE
SPRINGFIELD OH
45505-1406
US

V. Phone/Fax

Practice location:
  • Phone: 937-505-4394
  • Fax:
Mailing address:
  • Phone: 937-505-4394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN305615
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: