Basic Information
| Provider Information | |||||||||
| NPI: | 1861083008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRUKEMYER | ||||||||
| FirstName: | BRYNN | ||||||||
| MiddleName: | CHARLOTTE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 WEST ST | ||||||||
| Address2: | |||||||||
| City: | GENOA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197088012 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1504 US-224 EAST | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194273030 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2021 | ||||||||
| LastUpdateDate: | 01/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 50.006703RX | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 50.006703RX | 01 | OH | STATE LICENSE | OTHER |