Basic Information
| Provider Information | |||||||||
| NPI: | 1043591233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESANTIS | ||||||||
| FirstName: | BRYN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TROGDON | ||||||||
| OtherFirstName: | BRYN | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3400 OLENTANGY RIVER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147545500 | ||||||||
| FaxNumber: | 6144579519 | ||||||||
| Practice Location | |||||||||
| Address1: | 30701 CLEMENS RD # CRW10 | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441451074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406171212 | ||||||||
| FaxNumber: | 4406171213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2011 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F0711138 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0056677 | 05 | OH | MEDICAID |