Basic Information
| Provider Information | |||||||||
| NPI: | 1710015680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHROEDER | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636930 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 967 BELLEFONTAINE AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965077 | ||||||||
| FaxNumber: | 4199965483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 08/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 09021 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2759626 | 05 | OH | MEDICAID |