=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164746780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CINCINNATI NURSE PRACTITIONER SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2010
-----------------------------------------------------
Last Update Date | 05/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 990 BAYLEY PLACE DR
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45233-1664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-347-5475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 261
-----------------------------------------------------
City | CLEVES
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45002-0261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-347-5475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | MARY R PAINTER-ROMANELLO
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 513-347-5475
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | COA 03556-NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------