Healthcare Provider Details

I. General information

NPI: 1104113513
Provider Name (Legal Business Name): FATMATA ADDISON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

473 WOODMARK RUN
GAHANNA OH
43230
US

IV. Provider business mailing address

473 WOODMARK RUN
GAHANNA OH
43230-5030
US

V. Phone/Fax

Practice location:
  • Phone: 614-475-5911
  • Fax:
Mailing address:
  • Phone: 614-475-5911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number288852
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: