Healthcare Provider Details

I. General information

NPI: 1205509452
Provider Name (Legal Business Name): SLESSOR MAH TOH-FOMBANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2021
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 E BROAD ST STE 400
COLUMBUS OH
43213-2979
US

IV. Provider business mailing address

8732 LINICK DR
REYNOLDSBURG OH
43068-4782
US

V. Phone/Fax

Practice location:
  • Phone: 614-655-3345
  • Fax: 614-317-4689
Mailing address:
  • Phone: 614-772-4473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.456245
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0030416
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: