Provider Demographics
NPI:1194322842
Name:FERNOW, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:FERNOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 COLUMBUS LANCASTER RD NW LOT 248
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-1409
Mailing Address - Country:US
Mailing Address - Phone:740-243-5554
Mailing Address - Fax:
Practice Address - Street 1:2445 COLUMBUS LANCASTER RD NW LOT 248
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-1409
Practice Address - Country:US
Practice Address - Phone:740-243-5554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2303288Medicaid