Healthcare Provider Details

I. General information

NPI: 1609586064
Provider Name (Legal Business Name): NICHOLE HOFFBAUER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 S TRIMBLE RD
MANSFIELD OH
44906-3427
US

IV. Provider business mailing address

55 INDEPENDENCE DR
SHELBY OH
44875-1815
US

V. Phone/Fax

Practice location:
  • Phone: 419-529-4602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number108369
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: