Basic Information
| Provider Information | |||||||||
| NPI: | 1174596159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUNYON | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 741 BURNT POND RD | ||||||||
| Address2: | |||||||||
| City: | OSTRANDER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430619739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142167772 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1040 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433026416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403838080 | ||||||||
| FaxNumber: | 7403838084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/01/2018 | ||||||||
| NPIReactivationDate: | 10/10/2018 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN-308188 | OH | N | Nursing Service Providers | Registered Nurse | 363LF0000X | APRN.CNP.023698 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0333675 | 05 | OH | MEDICAID |