Basic Information
Provider Information | |||||||||
NPI: | 1275980443 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUTHERFORD | ||||||||
FirstName: | TIA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRUBER | ||||||||
OtherFirstName: | TIA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 329 N WEST ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458014332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192213072 | ||||||||
FaxNumber: | 4195495670 | ||||||||
Practice Location | |||||||||
Address1: | 200 HARDING AVE | ||||||||
Address2: |   | ||||||||
City: | KENTON | ||||||||
State: | OH | ||||||||
PostalCode: | 433261669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196795994 | ||||||||
FaxNumber: | 4192258878 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2016 | ||||||||
LastUpdateDate: | 08/01/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP19377 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.