Healthcare Provider Details

I. General information

NPI: 1134997257
Provider Name (Legal Business Name): RODELISA DOUGLAS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 GEORGESVILLE SQUARE DR
COLUMBUS OH
43228-3777
US

IV. Provider business mailing address

3549 ALBERTA ST
COLUMBUS OH
43228-1401
US

V. Phone/Fax

Practice location:
  • Phone: 614-335-0030
  • Fax:
Mailing address:
  • Phone: 614-381-4150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0035121
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: