Provider Demographics
NPI:1992773881
Name:EIDSON, ANGELA KAYE (LPN-IP)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:KAYE
Last Name:EIDSON
Suffix:
Gender:F
Credentials:LPN-IP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1350
Mailing Address - Country:US
Mailing Address - Phone:419-512-9384
Mailing Address - Fax:
Practice Address - Street 1:5805 KEMP RD
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:OH
Practice Address - Zip Code:44827-9646
Practice Address - Country:US
Practice Address - Phone:419-683-1214
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-089611164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2574781Medicaid