Basic Information
| Provider Information | |||||||||
| NPI: | 1275558272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOLLE | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4439 STATE ROUTE 159 STE 150 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456017833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407798840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4439 STATE ROUTE 159 STE 150 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456017833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407798840 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | COA.07052-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2368138 | 05 | OH | MEDICAID |