Basic Information
Provider Information | |||||||||
NPI: | 1922056498 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KERSTETTER | ||||||||
FirstName: | MOLLY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILCETICH | ||||||||
OtherFirstName: | MOLLY | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1 PARK WEST BLVD. | ||||||||
Address2: | SUITE 200 | ||||||||
City: | AKRON | ||||||||
State: | OH | ||||||||
PostalCode: | 443204219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3308699777 | ||||||||
FaxNumber: | 3308690052 | ||||||||
Practice Location | |||||||||
Address1: | 1 PARK WEST BLVD. | ||||||||
Address2: | SUITE 200 | ||||||||
City: | AKRON | ||||||||
State: | OH | ||||||||
PostalCode: | 443204219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3308699777 | ||||||||
FaxNumber: | 3308690052 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 02/04/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | NM08827 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   | 367A00000X | NM-08827 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 2750563 | 05 | OH |   | MEDICAID |