Healthcare Provider Details

I. General information

NPI: 1770908501
Provider Name (Legal Business Name): LOIS ANN HATHORN ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 08/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 HIGHLAND AVE
CINCINNATI OH
45219-2399
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-584-4061
  • Fax: 513-584-3349
Mailing address:
  • Phone: 513-585-5505
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCOA 15409 NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: