Healthcare Provider Details

I. General information

NPI: 1104556091
Provider Name (Legal Business Name): EMMA OVERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

10543 BROOKVILLE PHILLIPSBURG RD
BROOKVILLE OH
45309-7618
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-8000
  • Fax:
Mailing address:
  • Phone: 937-672-5282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0031504
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.392147
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: