Basic Information
| Provider Information | |||||||||
| NPI: | 1275953408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMPLE | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 FRANTZ RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145446356 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3705 OLENTANGY RIVER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432143467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142626772 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2014 | ||||||||
| LastUpdateDate: | 11/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.186505 | OH | N | Nursing Service Providers | Registered Nurse | 364SA2200X | COA.16623-NS | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 0112533 | 05 | OH | MEDICAID |