Healthcare Provider Details

I. General information

NPI: 1609535251
Provider Name (Legal Business Name): BEAUTY MARK AESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

866 E FRANKLIN ST STE C
CENTERVILLE OH
45459-5608
US

IV. Provider business mailing address

4801 DEER CRK
MIDDLETOWN OH
45042-5805
US

V. Phone/Fax

Practice location:
  • Phone: 937-867-7700
  • Fax:
Mailing address:
  • Phone: 937-867-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHELBY GONSALES
Title or Position: NURSE PRACTITIONER/OWNER
Credential: APRN
Phone: 937-867-7700