Basic Information
| Provider Information | |||||||||
| NPI: | 1518934090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANDIS | ||||||||
| FirstName: | NORMA | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3180 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372930247 | ||||||||
| FaxNumber: | 9232930960 | ||||||||
| Practice Location | |||||||||
| Address1: | 1114 N MONROE DRIVE | ||||||||
| Address2: | |||||||||
| City: | XENIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373728011 | ||||||||
| FaxNumber: | 9373766983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN121454 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0807005 | 05 | OH | MEDICAID |