Provider Demographics
NPI:1528293131
Name:OSBORNE, JACQUELINE LATRESE (LPN)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:LATRESE
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:LATREST
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:4041 BRUMBAUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45416-1610
Mailing Address - Country:US
Mailing Address - Phone:937-608-6396
Mailing Address - Fax:
Practice Address - Street 1:4041 BRUMBAUGH BOULEVARD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45416
Practice Address - Country:US
Practice Address - Phone:937-608-6396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH132618164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse