Provider Demographics
NPI:1083411003
Name:FETTY, DAKOTAH R (LPN)
Entity type:Individual
Prefix:
First Name:DAKOTAH
Middle Name:R
Last Name:FETTY
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 165
Mailing Address - Street 2:
Mailing Address - City:WEST FARMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44491-0165
Mailing Address - Country:US
Mailing Address - Phone:405-631-5864
Mailing Address - Fax:
Practice Address - Street 1:5338 OLD STATE RD
Practice Address - Street 2:
Practice Address - City:WEST FARMINGTON
Practice Address - State:OH
Practice Address - Zip Code:44491-8743
Practice Address - Country:US
Practice Address - Phone:440-563-1586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.155586.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse