Provider Demographics
NPI:1184479131
Name:PUGH, VIDA NICOLE
Entity type:Individual
Prefix:MISS
First Name:VIDA
Middle Name:NICOLE
Last Name:PUGH
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 1:2251 SARATOGA AVE SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44706-2150
Mailing Address - Country:US
Mailing Address - Phone:330-949-1805
Mailing Address - Fax:
Practice Address - Street 1:2251 SARATOGA AVE SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44706-2150
Practice Address - Country:US
Practice Address - Phone:330-949-1805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN471939163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse