Healthcare Provider Details

I. General information

NPI: 1063978690
Provider Name (Legal Business Name): ZACHARY CHARLES NIESE RN, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 ROAD P
PANDORA OH
45877-9733
US

IV. Provider business mailing address

16855 ROAD 5
PANDORA OH
45877-9755
US

V. Phone/Fax

Practice location:
  • Phone: 419-615-2983
  • Fax: 833-629-0555
Mailing address:
  • Phone: 419-615-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.024287
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: