Healthcare Provider Details

I. General information

NPI: 1578192290
Provider Name (Legal Business Name): BRAIDY NICOLE TANDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 REGENT ST STE 200
COLUMBUS OH
43219-6229
US

IV. Provider business mailing address

4200 REGENT ST STE 200
COLUMBUS OH
43219-6229
US

V. Phone/Fax

Practice location:
  • Phone: 877-870-1775
  • Fax: 614-968-8840
Mailing address:
  • Phone: 877-870-1775
  • Fax: 614-968-8840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number026329
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number105510
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: