Basic Information
| Provider Information | |||||||||
| NPI: | 1588270722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPEDALE | ||||||||
| FirstName: | JAIME | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 EDGEFIELD BLVD | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433025801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409144178 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1085 POLARIS PKWY | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432402004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145050778 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2020 | ||||||||
| LastUpdateDate: | 02/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 026524 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.