Healthcare Provider Details

I. General information

NPI: 1558616680
Provider Name (Legal Business Name): THOMAS WALLACE GITCHEL JR. STNA, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2012
Last Update Date: 07/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9470 HUNT RD
ST LOUISVILLE OH
43071-9758
US

IV. Provider business mailing address

9470 HUNT RD
ST LOUISVILLE OH
43071-9758
US

V. Phone/Fax

Practice location:
  • Phone: 317-695-0153
  • Fax:
Mailing address:
  • Phone: 317-695-0153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number377484
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number400929290609
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: