Healthcare Provider Details

I. General information

NPI: 1194610212
Provider Name (Legal Business Name): BAILEY ELIZABETH EICKHOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W GRAND AVE
DAYTON OH
45405-7538
US

IV. Provider business mailing address

1568 ASHLEY CT APT A
FAIRBORN OH
45324-6584
US

V. Phone/Fax

Practice location:
  • Phone: 937-723-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.0021572
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: