Healthcare Provider Details

I. General information

NPI: 1417548256
Provider Name (Legal Business Name): NIESE FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3387 ROAD K3
OTTAWA OH
45875-8741
US

IV. Provider business mailing address

2040 ROAD P
PANDORA OH
45877-9733
US

V. Phone/Fax

Practice location:
  • Phone: 419-615-2983
  • Fax:
Mailing address:
  • Phone: 419-615-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ZACHARY CHARLES NIESE
Title or Position: OWNER
Credential: MSN, APRN, FNP-C
Phone: 419-615-2983