Healthcare Provider Details

I. General information

NPI: 1720904394
Provider Name (Legal Business Name): ELIZABETH LAUREN NIEMIEC PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 BUCKLES CT N STE 100
GAHANNA OH
43230-6927
US

IV. Provider business mailing address

680 BUCKLES CT N STE 100
GAHANNA OH
43230-6927
US

V. Phone/Fax

Practice location:
  • Phone: 614-986-0125
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.0099997RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: