Healthcare Provider Details

I. General information

NPI: 1467879635
Provider Name (Legal Business Name): CONNIE S FORUP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONNIE S SLUPECKI

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 CHERRY ST
TOLEDO OH
43608-2906
US

IV. Provider business mailing address

1212 CHERRY ST
TOLEDO OH
43608-2906
US

V. Phone/Fax

Practice location:
  • Phone: 419-936-7415
  • Fax:
Mailing address:
  • Phone: 419-936-7415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN318170
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: