Basic Information
Provider Information | |||||||||
NPI: | 1669442455 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANDLIK | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN.CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432021559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142936196 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 W 10TH AVE | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432101280 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142936196 | ||||||||
FaxNumber: | 6143660073 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2006 | ||||||||
LastUpdateDate: | 12/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | COA.03438-NP | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | APRN.CNP.03438 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 2309120 | 05 | OH |   | MEDICAID |