Healthcare Provider Details

I. General information

NPI: 1952961039
Provider Name (Legal Business Name): CIJI LACOLE BOOTHE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 REGENT ST STE 200
COLUMBUS OH
43219-6229
US

IV. Provider business mailing address

870 COUNTY ROAD 412
OPP AL
36467-8011
US

V. Phone/Fax

Practice location:
  • Phone: 877-581-2210
  • Fax: 614-968-8840
Mailing address:
  • Phone: 334-504-1894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-121182
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-121182
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: