Healthcare Provider Details

I. General information

NPI: 1144538885
Provider Name (Legal Business Name): ANJA VESANEN BROKAW NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 W BROAD ST LOWER LIGHTS CHRISTIAN HEALTH CENTER
COLUMBUS OH
43222-1317
US

IV. Provider business mailing address

1160 W BROAD ST LOWER LIGHTS CHRISTIAN HEALTH CENTER
COLUMBUS OH
43222-1317
US

V. Phone/Fax

Practice location:
  • Phone: 614-274-1455
  • Fax: 614-274-2040
Mailing address:
  • Phone: 614-274-1455
  • Fax: 614-274-2040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN.394211-COA1
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.11799-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: