Healthcare Provider Details

I. General information

NPI: 1881314946
Provider Name (Legal Business Name): MISS KEATON NICHOLE EILERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 BON AIR DR
SIDNEY OH
45365-2009
US

IV. Provider business mailing address

525 BON AIR DR
SIDNEY OH
45365-2009
US

V. Phone/Fax

Practice location:
  • Phone: 937-638-5807
  • Fax:
Mailing address:
  • Phone: 937-638-5807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: