Healthcare Provider Details

I. General information

NPI: 1710692579
Provider Name (Legal Business Name): DEVON ELENA BRODINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 FOREST DR
NEW ALBANY OH
43054-8167
US

IV. Provider business mailing address

6480 HARRISON AVE STE 201
CINCINNATI OH
45247-7961
US

V. Phone/Fax

Practice location:
  • Phone: 614-890-6555
  • Fax: 614-523-7557
Mailing address:
  • Phone: 513-795-4049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007969
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: