Healthcare Provider Details

I. General information

NPI: 1083642094
Provider Name (Legal Business Name): MARY ALICE MOMEYER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 BETHEL RD STE F
COLUMBUS OH
43220-1804
US

IV. Provider business mailing address

2121 BETHEL RD STE F
COLUMBUS OH
43220-1804
US

V. Phone/Fax

Practice location:
  • Phone: 614-457-3100
  • Fax: 614-457-3200
Mailing address:
  • Phone: 614-457-3100
  • Fax: 614-457-3200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN.218736-COA1
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: