Provider Demographics
NPI:1447865548
Name:CANADA, KATRINA JEAN (INDEPENDENT PROVIDER)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:JEAN
Last Name:CANADA
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-2844
Mailing Address - Country:US
Mailing Address - Phone:740-692-5424
Mailing Address - Fax:
Practice Address - Street 1:288 ROSE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-2844
Practice Address - Country:US
Practice Address - Phone:419-617-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5101502376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0400577Medicaid