Healthcare Provider Details

I. General information

NPI: 1659966042
Provider Name (Legal Business Name): ANGELA BOEDEKER (EBERHARD) CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W MAIN ST
CIRCLEVILLE OH
43113-1654
US

IV. Provider business mailing address

12175 HEFFNER RD
KINGSTON OH
45644-9661
US

V. Phone/Fax

Practice location:
  • Phone: 740-572-3088
  • Fax:
Mailing address:
  • Phone: 740-572-3088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0028441
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN.CNP.0028441
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: