Provider Demographics
NPI:1144639550
Name:JAGODZINSKI, STEPHANIE A (CNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:JAGODZINSKI
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SEAGATE STE 800
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1558
Mailing Address - Country:US
Mailing Address - Phone:567-585-0225
Mailing Address - Fax:419-214-3564
Practice Address - Street 1:3430 SECOR RD STE 425
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1547
Practice Address - Country:US
Practice Address - Phone:567-585-0225
Practice Address - Fax:419-214-3564
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 16018-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0113079Medicaid
OHH406060OtherMEDICARE PIN
OHH406062OtherMEDICARE PIN-CENTRAL