Healthcare Provider Details

I. General information

NPI: 1215377262
Provider Name (Legal Business Name): ASONGACHA MBETAZI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 SULLIVANT AVE
COLUMBUS OH
43222-1055
US

IV. Provider business mailing address

6363 CASADO DR
COLUMBUS OH
43213-1579
US

V. Phone/Fax

Practice location:
  • Phone: 614-752-0333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP.0042705
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.395246
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: