Healthcare Provider Details

I. General information

NPI: 1346757853
Provider Name (Legal Business Name): NICOLE WAYMAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

4030 SMITH RD STE 325
CINCINNATI OH
45209-1937
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2211
  • Fax:
Mailing address:
  • Phone: 513-817-1172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number257025325
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: