=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063887099
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNIE LONGENECKER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2015
-----------------------------------------------------
Last Update Date | 12/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5151 PFEIFFER RD STE 350
-----------------------------------------------------
City | BLUE ASH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-4854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-358-2036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 LYONS RD SUITE A
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45458-1882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-438-9100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | COA.18459-NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------