Ohio Independent Provider Network Listing Form

Ohio Independent Provider Network

Full Name

LPN

(Your last name will not be displayed)

Email Address

Contact Phone

Provider No.

(will not be displayed)

*Please list your region
so I will know what
area/s to list your Ad.

Region Served

County/areas served

Consumer Preference

Provide a brief summary of the days, shifts, or hours you are
available; you are responsible for listing your contact info in
your summary (email and/or phone number) for consumers to
be able to contact you. List only pertinent experience.

You will be listed ASAP. Please allow at least 24 hours.

* Please remember to update any of your info
should it change. Thanks for your cooperation!

Nurses Providing Exceptional Care

Independent Provider Nurse Listing Form

There is a $6.00 Availability Listing Fee (Per Region) for 1 year. After
completion of this form, you will be redirected to a page with the "Buy
Now" button -or- you may send a check to:
Shasme Jones, 7235 Scottwood Avenue, Cincinnati, OH 45237

Shasme Jones

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