=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427709229
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYDNAE COLLYN HURLBUT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2022
-----------------------------------------------------
Last Update Date | 01/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2739 COUNTY ROAD 91
-----------------------------------------------------
City | BELLEFONTAINE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43311-9007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-592-2901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 E MAIN ST
-----------------------------------------------------
City | BELLE CENTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43310-9751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-844-9868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number | LPN.174177.MEDS-IV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------