Provider Demographics
NPI:1104948843
Name:FETHEROLF, JANICE LEE (AID)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:LEE
Last Name:FETHEROLF
Suffix:
Gender:F
Credentials:AID
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15231 ST RT #93 SOUTH
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138
Mailing Address - Country:US
Mailing Address - Phone:740-380-6210
Mailing Address - Fax:
Practice Address - Street 1:12209 LECORNE ST
Practice Address - Street 2:
Practice Address - City:MILLERSPORT
Practice Address - State:OH
Practice Address - Zip Code:43046
Practice Address - Country:US
Practice Address - Phone:740-507-8544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253359374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH105552217999Medicaid