Basic Information
| Provider Information | |||||||||
| NPI: | 1043554819 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUESTONE VITALITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 938 | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430540938 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7625 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430169649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147171800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | SENITA | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6147171800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | COA11833 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.