Healthcare Provider Details

I. General information

NPI: 1013387679
Provider Name (Legal Business Name): VALERIE MBACKE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 ANDERSON FERRY RD
CINCINNATI OH
45238-3328
US

IV. Provider business mailing address

11509 RAPHAEL PL
CINCINNATI OH
45240-2015
US

V. Phone/Fax

Practice location:
  • Phone: 513-922-4271
  • Fax:
Mailing address:
  • Phone: 937-823-9658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA-17960-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: