Provider Demographics
NPI:1336358456
Name:FORMICK, MICHELLE RUTH
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RUTH
Last Name:FORMICK
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 1:748 DIANE AVE
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-4720
Mailing Address - Country:US
Mailing Address - Phone:330-653-9073
Mailing Address - Fax:
Practice Address - Street 1:748 DIANE AVE
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-4720
Practice Address - Country:US
Practice Address - Phone:330-653-9073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2638257374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide