Provider Demographics
NPI:1316263510
Name:FOTHERINGHAM, CRYSTAL L (LPN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:FOTHERINGHAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-2330
Mailing Address - Country:US
Mailing Address - Phone:330-244-6288
Mailing Address - Fax:
Practice Address - Street 1:326 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-2330
Practice Address - Country:US
Practice Address - Phone:330-244-6288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH137900164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse