Healthcare Provider Details

I. General information

NPI: 1043837594
Provider Name (Legal Business Name): KAITLYN E FICKIESEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 E LONG ST
COLUMBUS OH
43203-2045
US

IV. Provider business mailing address

1751 E LONG ST
COLUMBUS OH
43203-2045
US

V. Phone/Fax

Practice location:
  • Phone: 614-253-8050
  • Fax:
Mailing address:
  • Phone: 614-253-8050
  • Fax: 937-322-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2005075
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberS.2005075
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: