Basic Information
| Provider Information | |||||||||
| NPI: | 1245305051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMFAHR | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | C.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 SOUTHERN BLVD STE 401 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555002873 | ||||||||
| FaxNumber: | 9372813913 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 SOUTHERN BLVD STE 401 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555002873 | ||||||||
| FaxNumber: | 9372813913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | COA 08082 NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | APRN.CNP.08082 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 0000000363681 | 01 | OH | ANTHEM | OTHER | 2543493 | 05 | OH | MEDICAID |