Healthcare Provider Details

I. General information

NPI: 1043802093
Provider Name (Legal Business Name): ROSEANN HATHAWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 COUNTY ROAD 64
WILLOW WOOD OH
45696-9073
US

IV. Provider business mailing address

1698 COUNTY ROAD 64
WILLOW WOOD OH
45696-9073
US

V. Phone/Fax

Practice location:
  • Phone: 740-643-0421
  • Fax:
Mailing address:
  • Phone: 740-643-0421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: