Healthcare Provider Details

I. General information

NPI: 1700169117
Provider Name (Legal Business Name): KOMI KPOGLI RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 URICH DR
PICKERINGTON OH
43147-7833
US

IV. Provider business mailing address

124 URICH DR
PICKERINGTON OH
43147-7833
US

V. Phone/Fax

Practice location:
  • Phone: 859-457-0032
  • Fax:
Mailing address:
  • Phone: 859-457-0032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberAPRN.CNS.019314
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number316816
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: