Provider Demographics
NPI:1487282661
Name:LANGFORD, JENALISA CORINNE
Entity type:Individual
Prefix:
First Name:JENALISA
Middle Name:CORINNE
Last Name:LANGFORD
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 1:2200 MIAMI VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4783
Mailing Address - Country:US
Mailing Address - Phone:937-668-7873
Mailing Address - Fax:
Practice Address - Street 1:2200 MIAMI VALLEY DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4783
Practice Address - Country:US
Practice Address - Phone:937-668-7873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.354369163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0178903Medicaid