Healthcare Provider Details

I. General information

NPI: 1366141772
Provider Name (Legal Business Name): KATHRYN AMANDA BOEHMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2023
Last Update Date: 06/10/2023
Certification Date: 06/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 OLENTANGY RIVER RD
COLUMBUS OH
43214-3998
US

IV. Provider business mailing address

4802 INISHEER CT
DUBLIN OH
43017-9170
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-5000
  • Fax:
Mailing address:
  • Phone: 614-795-1997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008193RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: