Provider Demographics
NPI:1255382479
Name:OGLESBY, TINA R (LPN)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:R
Last Name:OGLESBY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 STUBBS DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-3106
Mailing Address - Country:US
Mailing Address - Phone:937-361-8161
Mailing Address - Fax:
Practice Address - Street 1:215 STUBBS DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-3106
Practice Address - Country:US
Practice Address - Phone:937-361-8161
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN113315164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2415658Medicaid