Basic Information
Provider Information | |||||||||
NPI: | 1396111597 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BORN | ||||||||
FirstName: | ADJONDI | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NURSE PRACTITIONER | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOSSEAUX | ||||||||
OtherFirstName: | ADJONDI | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NURSE PRACTITIONER | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 13611 BAIRD RD | ||||||||
Address2: |   | ||||||||
City: | OBERLIN | ||||||||
State: | OH | ||||||||
PostalCode: | 440749665 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4403871238 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5940 OAK POINT RD | ||||||||
Address2: |   | ||||||||
City: | LORAIN | ||||||||
State: | OH | ||||||||
PostalCode: | 440534100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4409883705 | ||||||||
FaxNumber: | 4409887433 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2015 | ||||||||
LastUpdateDate: | 03/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.021734 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 0243931 | 05 | OH |   | MEDICAID |